Healthcare Provider Details

I. General information

NPI: 1154481802
Provider Name (Legal Business Name): MMC SURGICAL CRITICAL CARE FACULTY PRACTICE PLAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 10TH AVE
BROOKLYN NY
11219-2916
US

IV. Provider business mailing address

GPO BOX 27374
NEW YORK NY
10087-7374
US

V. Phone/Fax

Practice location:
  • Phone: 718-283-8773
  • Fax: 718-283-8773
Mailing address:
  • Phone: 718-283-8773
  • Fax: 718-283-8773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number
License Number State

VIII. Authorized Official

Name: GAIL SIMHON
Title or Position: VP
Credential:
Phone: 718-283-7285