Healthcare Provider Details

I. General information

NPI: 1316259831
Provider Name (Legal Business Name): 758 MEDICAL SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

758 56TH ST
BROOKLYN NY
11220-3504
US

IV. Provider business mailing address

758 56TH ST
BROOKLYN NY
11220-3504
US

V. Phone/Fax

Practice location:
  • Phone: 718-436-3023
  • Fax: 718-871-2805
Mailing address:
  • Phone: 718-436-3023
  • Fax: 718-871-2805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number234283
License Number StateNY

VIII. Authorized Official

Name: DR. SEONGPAN SI
Title or Position: PRESIDENT
Credential: MD
Phone: 718-436-3023