Healthcare Provider Details

I. General information

NPI: 1619250073
Provider Name (Legal Business Name): IM PRIMARY MEDICAL CARE , PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 LENOX RD SUITE 1
BROOKLYN NY
11203-2603
US

IV. Provider business mailing address

900 LENOX RD SUITE 1
BROOKLYN NY
11203-2603
US

V. Phone/Fax

Practice location:
  • Phone: 718-485-5500
  • Fax:
Mailing address:
  • Phone: 718-485-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number254486
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number254486
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number254486
License Number StateNY

VIII. Authorized Official

Name: IRINA MIKHEYEVA
Title or Position: OWNER
Credential: D.O.
Phone: 718-485-5500