Healthcare Provider Details

I. General information

NPI: 1366624140
Provider Name (Legal Business Name): DOUGLASTON ENDOSCOPY OBS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 02/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24102 NORTHERN BLVD
DOUGLASTON NY
11362-1061
US

IV. Provider business mailing address

24102 NORTHERN BLVD
DOUGLASTON NY
11362-1061
US

V. Phone/Fax

Practice location:
  • Phone: 718-461-0163
  • Fax: 718-358-5570
Mailing address:
  • Phone: 718-461-0163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number StateNY

VIII. Authorized Official

Name: DR. NEIL MARTIN BRODSKY
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 718-461-0163