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General NPI Number Information
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NPI Number | 1083785083
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Entity Type | Organization
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Legal Business Name | INTERCOUNTY OBGYN
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Dates
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Enumeration Date | 11/13/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 6608 FRESH POND ROAD
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City | RIDGEWOOD
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State | NY
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Zip | 11385
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Country | US
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Telephone | 718-497-3045
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Fax | 718-497-3126
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Provider Business Mailing Address
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Address Line | PO BOX 370508
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City | BROOKLYN
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State | NY
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Zip | 11237
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Country | US
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Telephone | 718-497-3121
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Fax | 718-497-3126
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Authorized Official
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Title or Position | OWNER PHYSICIAN
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Name | DR. BALA KB RAVI SR.
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Credential | MD
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Telephone | 718-497-3121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 203725
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License Number State | NY
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