Healthcare Provider Details

I. General information

NPI: 1346545076
Provider Name (Legal Business Name): BREWSTER MEDICAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 BREWSTER ST
GLEN COVE NY
11542-2510
US

IV. Provider business mailing address

3 BREWSTER ST
GLEN COVE NY
11542-2510
US

V. Phone/Fax

Practice location:
  • Phone: 151-675-9770
  • Fax:
Mailing address:
  • Phone: 151-675-9770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number127749
License Number StateNY

VIII. Authorized Official

Name: MR. JOSEPH GALLO
Title or Position: PRESIDENT
Credential: MD
Phone: 15167597702