MEDICARE: MIDWOOD GENERAL AND PHYSICAL MEDICINE, P.C.

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	208100000X	Physical Medicine & Rehabilitation Physician	260559	NY

General Provider Information

NPI Number	:	1174895429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWOOD GENERAL AND PHYSICAL MEDICINE, P.C.

Provider Business Mailing Address
First Line	:	62 NEWBERRY AVE
Second Line	:	1C
City	:	STATEN ISLAND
State	:	NY
Zip	:	10304-4144
Country	:	US
Telephone Number	:	646-725-8283
Fax Number	:

Provider Business Practice Location Address
First Line	:	1122 CONEY ISLAND AVE
Second Line	:	SUITE 205
City	:	BROOKLYN
State	:	NY
Zip	:	11230-2345
Country	:	US
Telephone Number	:	718-725-8341
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. FARRUQ SIDDIQUI
Credential	:	M.D.
Telephone Number	:	646-725-8283

Provider Enumeration Date	:	02/02/2012
Last Update Date	:	03/23/2012

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