Healthcare Provider Details

I. General information

NPI: 1023251261
Provider Name (Legal Business Name): MEDICAL PRACTICE NY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2009
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 W 86TH ST APT 1C
NEW YORK NY
10024-3663
US

IV. Provider business mailing address

5 W 86TH ST APT 1C
NEW YORK NY
10024-3663
US

V. Phone/Fax

Practice location:
  • Phone: 212-874-0143
  • Fax:
Mailing address:
  • Phone: 212-874-0143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number185185
License Number StateNY

VIII. Authorized Official

Name: MS. YELENA MAMEDOVA-BRAZ
Title or Position: OWNER
Credential: MD
Phone: 212-874-0143