Healthcare Provider Details

I. General information

NPI: 1073067393
Provider Name (Legal Business Name): M. FREEMAN MEDICAL PRACTICE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2016
Last Update Date: 08/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 W 147TH ST
NEW YORK NY
10031-4808
US

IV. Provider business mailing address

407 W 147TH ST
NEW YORK NY
10031-4808
US

V. Phone/Fax

Practice location:
  • Phone: 212-281-5613
  • Fax: 212-862-4923
Mailing address:
  • Phone: 212-281-5613
  • Fax: 212-862-4923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number080452
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number080452
License Number StateNY

VIII. Authorized Official

Name: MELISSA M FREEMAN
Title or Position: AUTHORIZE OFFICIAL
Credential: MD
Phone: 917-864-0708