=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285355248
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHEAST FAMILY MEDICAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2022
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 667 61ST ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11220-4123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-554-6477
-----------------------------------------------------
Fax | 347-889-5909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 138 MAIN ST # 1009
-----------------------------------------------------
City | EAST ROCKAWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11518-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-554-6477
-----------------------------------------------------
Fax | 347-889-5915
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. FRANK SUPPA
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 516-554-6477
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------