MEDICARE: BROOKDALE HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center	2592091	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2592091	OTHER	NY	STATE OF NEW YORK

General Provider Information

NPI Number	:	1104127984
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKDALE HOSPITAL

Provider Business Mailing Address
First Line	:	2258 84TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-3328
Country	:	US
Telephone Number	:	347-277-9084
Fax Number	:

Provider Business Practice Location Address
First Line	:	2258 84TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-3328
Country	:	US
Telephone Number	:	347-277-9084
Fax Number	:

Authorized Official
Title or Position	:	PHISICIAN
Name	:	TATYANA SEMENOVA
Credential	:	MD
Telephone Number	:	347-277-9084

Provider Enumeration Date	:	11/09/2010
Last Update Date	:	11/09/2010

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Directions to “BROOKDALE HOSPITAL ” Practice Location

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