=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447791132
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOKLYN PLAZA MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2017
-----------------------------------------------------
Last Update Date | 03/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 FULTON ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11217-1517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-596-9800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 650 FULTON ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11217-1517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-596-9800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. LAZETA DUNCAN MOORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-596-9800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number | 132006
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------