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General NPI Number Information
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NPI Number | 1386036143
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Entity Type | Organization
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Legal Business Name | ADVANTA MEDICAL PC
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Dates
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Enumeration Date | 03/03/2015
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Last Update Date | 03/06/2015
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Provider Practice Location Address
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Address Line | 2818 OCEAN AVE STE 1
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City | BROOKLYN
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State | NY
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Zip | 11235-3121
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Country | US
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Telephone | 718-934-8484
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Fax | 718-934-4267
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Provider Business Mailing Address
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Address Line | 2818 OCEAN AVE STE 1
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City | BROOKLYN
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State | NY
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Zip | 11235-3170
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Country | US
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Telephone | 718-934-8484
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Fax | 718-934-4267
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Authorized Official
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Title or Position | DOCTOR
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Name | MICHAEL RISKEVICH
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Credential | DO
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Telephone | 718-934-8484
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 208815
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License Number State | NY
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