=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114435765
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. SHTEIN MEDICAL P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2018
-----------------------------------------------------
Last Update Date | 01/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1068 CONEY ISLAND AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11230-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-684-1760
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 352 52ND ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11220-1810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DO
-----------------------------------------------------
Name | DR. LYUDMILA SHTEIN
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 718-708-0875
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 259564
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------