Healthcare Provider Details

I. General information

NPI: 1831426295
Provider Name (Legal Business Name): SEL MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2009
Last Update Date: 11/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 FULTON ST
BROOKLYN NY
11201-5137
US

IV. Provider business mailing address

350 FULTON ST
BROOKLYN NY
11201-5137
US

V. Phone/Fax

Practice location:
  • Phone: 718-875-9200
  • Fax: 718-875-9211
Mailing address:
  • Phone: 718-875-9200
  • Fax: 718-875-9211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number001137
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number001137
License Number StateNY

VIII. Authorized Official

Name: DR. KARL LATORTUE
Title or Position: MD
Credential: MD
Phone: 718-875-9200