Healthcare Provider Details

I. General information

NPI: 1073923561
Provider Name (Legal Business Name): COLORECTAL CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2014
Last Update Date: 05/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2647 CONEY ISLAND AVE
BROOKLYN NY
11223-5502
US

IV. Provider business mailing address

7000 BAY PKWY
BROOKLYN NY
11204-5531
US

V. Phone/Fax

Practice location:
  • Phone: 718-743-4450
  • Fax:
Mailing address:
  • Phone: 718-743-4450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MYCHAILO FULMES
Title or Position: SOLE MBR
Credential: MD
Phone: 718-743-4450