Healthcare Provider Details

I. General information

NPI: 1639434061
Provider Name (Legal Business Name): FAR ROCKAWAY MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 BEACH 20TH ST
FAR ROCKAWAY NY
11691-3502
US

IV. Provider business mailing address

712 BEACH 20TH ST
FAR ROCKAWAY NY
11691-3502
US

V. Phone/Fax

Practice location:
  • Phone: 718-327-7457
  • Fax: 718-327-7539
Mailing address:
  • Phone: 718-327-7457
  • Fax: 718-327-7539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JEAN-PIERRE BARAKAT
Title or Position: OWNER
Credential: MD
Phone: 718-327-7457