MEDICARE: KELLY BRANT PIKE D.O.

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	207Q00000X	Family Medicine Physician	287255	NY

General Provider Information

NPI Number	:	1235524794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY BRANT PIKE D.O.

Provider Business Mailing Address
First Line	:	1824 MADISON AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10035-3832
Country	:	US
Telephone Number	:	212-423-4500
Fax Number	:

Provider Business Practice Location Address
First Line	:	1824 MADISON AVE
Second Line	:	5TH FLOOR
City	:	NEW YORK CITY
State	:	NY
Zip	:	10035
Country	:	US
Telephone Number	:	212-423-4500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2015
Last Update Date	:	10/29/2025

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