Healthcare Provider Details

I. General information

NPI: 1477569879
Provider Name (Legal Business Name): MMC PEDIATRIC AMBULATORY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 57TH STREET
BROOKLYN NY
11219
US

IV. Provider business mailing address

977 48TH STREET ATTENTION: KATHLYN ORLANDO
BROOKLYN NY
11219
US

V. Phone/Fax

Practice location:
  • Phone: 718-283-3640
  • Fax: 718-283-3602
Mailing address:
  • Phone: 718-283-8015
  • Fax: 718-635-7235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN SHELOV
Title or Position: CHAIRMAN, DEPARTMENT OF PEDIATRICS
Credential: MD
Phone: 718-283-7500