Healthcare Provider Details

I. General information

NPI: 1578580650
Provider Name (Legal Business Name): SEONGPAN PHYSICIAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5517 7TH AVE FL 1
BROOKLYN NY
11220-3519
US

IV. Provider business mailing address

247 BAY 23RD ST
BROOKLYN NY
11214-6108
US

V. Phone/Fax

Practice location:
  • Phone: 718-436-3023
  • Fax: 718-436-3023
Mailing address:
  • Phone: 718-449-4966
  • Fax: 718-449-4966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number234283
License Number StateNY

VIII. Authorized Official

Name: MRS. SEONGPAN SI
Title or Position: PRESIDENT
Credential: M. D.
Phone: 718-436-3023