=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033730148
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PJP MEDICAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2020
-----------------------------------------------------
Last Update Date | 04/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 489 ATLANTIC AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11217-2985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-423-2407
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 MOUNT JOY AVE
-----------------------------------------------------
City | FREEPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11520-1443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PATRICK JEAN-PIERRE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 516-423-2407
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------