=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417033572
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVANGUARD MEDICAL GROUP, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2006
-----------------------------------------------------
Last Update Date | 10/19/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2076 E 13TH ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11229-3304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-382-7909
-----------------------------------------------------
Fax | 718-382-7912
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2076 E 13TH ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11229-3304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-382-7909
-----------------------------------------------------
Fax | 718-382-7912
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. MARK GLADSTEIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 718-382-7900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 205366
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------