MEDICARE: SEA GATE MEDICAL

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	207QA0505X	Adult Medicine Physician	205927	NY

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

General Provider Information

NPI Number	:	1316234669
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEA GATE MEDICAL

Provider Business Mailing Address
First Line	:	2580 OCEAN PKWY
Second Line	:	APT. 2L
City	:	BROOKLYN
State	:	NY
Zip	:	11235-7746
Country	:	US
Telephone Number	:	718-236-5077
Fax Number	:	718-715-1437

Provider Business Practice Location Address
First Line	:	1961 CONEY ISLAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11223-2328
Country	:	US
Telephone Number	:	718-344-7637
Fax Number	:	718-490-1468

Authorized Official
Title or Position	:	DO
Name	:	VALENTIN PRIDATKO
Credential	:	DO
Telephone Number	:	718-236-5077

Provider Enumeration Date	:	07/07/2011
Last Update Date	:	07/07/2011

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Directions to “SEA GATE MEDICAL ” Practice Location

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