=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316234669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEA GATE MEDICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2011
-----------------------------------------------------
Last Update Date | 07/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1961 CONEY ISLAND AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11223-2328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-344-7637
-----------------------------------------------------
Fax | 718-490-1468
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2580 OCEAN PKWY APT. 2L
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235-7746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-236-5077
-----------------------------------------------------
Fax | 718-715-1437
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DO
-----------------------------------------------------
Name | VALENTIN PRIDATKO
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 718-236-5077
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | 205927
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------