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General NPI Number Information
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NPI Number | 1073835641
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Entity Type | Organization
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Legal Business Name | BLUE GREEN HORIZONS OFFICE BASED SURGERY PLLC
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Dates
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Enumeration Date | 02/23/2010
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Last Update Date | 02/23/2010
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Provider Practice Location Address
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Address Line | 200 BROOKLYN AVE
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City | BROOKLYN
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State | NY
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Zip | 11213-1908
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Country | US
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Telephone | 718-498-7888
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Fax | 718-604-7890
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Provider Business Mailing Address
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Address Line | 200 BROOKLYN AVE
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City | BROOKLYN
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State | NY
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Zip | 11213-1908
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Country | US
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Telephone | 718-498-7888
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Fax | 718-604-7890
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Authorized Official
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Title or Position | OWNER
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Name | SHELBY K. SAMUEL
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Credential | M.D.
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Telephone | 718-498-7888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 176352
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License Number State | NY
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