=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295957652
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAR ROCKAWAY MEDICAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 10/27/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 714 BEACH 20TH ST
-----------------------------------------------------
City | FAR ROCKAWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-686-6700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 714 BEACH 20TH ST
-----------------------------------------------------
City | FAR ROCKAWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11691-3502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-327-5400
-----------------------------------------------------
Fax | 718-327-5434
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SERGEY GABINSKY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-327-5400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 199910
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------