=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699882829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAY RIDGE ORTHOPEDIC ASSOCIATES, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 476 BAY RIDGE PKWY
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11209-2702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-305-4633
-----------------------------------------------------
Fax | 914-305-5587
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 476 BAY RIDGE PKWY
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11209-2702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-305-4633
-----------------------------------------------------
Fax | 914-305-5587
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | EHAB SANDUBY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 914-305-4633
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 104095-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------