MEDICARE: PBGS, LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1164848453
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PBGS, LLC

Provider Business Mailing Address
First Line	:	14 DEKALB AVE
Second Line	:	4TH FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11201-5311
Country	:	US
Telephone Number	:	718-408-4999
Fax Number	:

Provider Business Practice Location Address
First Line	:	14 DEKALB AVE
Second Line	:	4TH FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11201-5311
Country	:	US
Telephone Number	:	718-408-4999
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DMITRIY BRONFMAN
Credential	:	MD
Telephone Number	:	718-408-4999

Provider Enumeration Date	:	03/11/2014
Last Update Date	:	11/15/2015

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