Healthcare Provider Details

I. General information

NPI: 1346791845
Provider Name (Legal Business Name): MAIMONIDES MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 10TH AVE DEPARTMENT OF MEDICINE ADMINISTRATION BUILDING 301
BROOKLYN NY
11219
US

IV. Provider business mailing address

4802 10TH AVE DEPARTMENT OF MEDICINE ADMINISTRATION BUILDING 301
BROOKLYN NY
11219
US

V. Phone/Fax

Practice location:
  • Phone: 718-283-8137
  • Fax:
Mailing address:
  • Phone: 718-283-8137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number020010-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number020010-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number020010-1
License Number StateNY

VIII. Authorized Official

Name: IGNAZIO DIMINO
Title or Position: CHIEF PHYSICIAN ASSISTANT, DOM
Credential: PA-C
Phone: 718-283-8137