Healthcare Provider Details

I. General information

NPI: 1730638115
Provider Name (Legal Business Name): 1110 PENNSYLVANIA AVENUE MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2016
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 PENNSYLVANIA AVE SUITE 5
BROOKLYN NY
11207-9003
US

IV. Provider business mailing address

1110 PENNSYLVANIA AVE SUITE 5
BROOKLYN NY
11207-9003
US

V. Phone/Fax

Practice location:
  • Phone: 646-942-2842
  • Fax:
Mailing address:
  • Phone: 646-942-2842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JACQUELINE STOREY
Title or Position: PHYSICIAN
Credential: MD
Phone: 646-942-2842