MEDICARE: EVERGREEN MEDICAL PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207RN0300X	Nephrology Physician
2	207RR0500X	Rheumatology Physician
3	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician
4	2084N0400X	Neurology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164664652
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN MEDICAL PLLC

Provider Business Mailing Address
First Line	:	755-759 61ST STREET
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-4211
Country	:	US
Telephone Number	:	718-680-8881
Fax Number	:	718-680-7880

Provider Business Practice Location Address
First Line	:	755-759 61ST STREET
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-4211
Country	:	US
Telephone Number	:	718-680-8881
Fax Number	:	718-680-7880

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MISS MAY LIN
Credential	:
Telephone Number	:	718-680-8881

Provider Enumeration Date	:	03/30/2009
Last Update Date	:	06/03/2009

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Directions to “EVERGREEN MEDICAL PLLC ” Practice Location

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