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General NPI Number Information
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NPI Number | 1114204682
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Entity Type | Organization
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Legal Business Name | MARVIN BASE MD PC
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Dates
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Enumeration Date | 11/10/2011
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Last Update Date | 11/10/2011
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Provider Practice Location Address
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Address Line | 210-08 NORTHERN BLVD
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City | BAYSIDE
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State | NY
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Zip | 11361
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Country | US
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Telephone | 718-281-4461
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Fax | 718-281-0566
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Provider Business Mailing Address
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Address Line | 210-08 NORTHERN BLVD
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City | BAYSIDE
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State | NY
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Zip | 11361
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Country | US
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Telephone | 718-281-4461
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Fax | 718-281-0566
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Authorized Official
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Title or Position | PHYSICIAN/PRINCIPAL
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Name | MARVIN BASE
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Credential | M.D
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Telephone | 718-281-4461
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | NY187770
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License Number State | NY
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