MEDICARE: ABBYDEK FAMILY MEDICAL PRACTICE PC

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	261QP2300X	Primary Care Clinic/Center	202847	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
2	202847	OTHER	NY	LICENSE

General Provider Information

NPI Number	:	1447535323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABBYDEK FAMILY MEDICAL PRACTICE PC

Provider Business Mailing Address
First Line	:	7935 153RD ST
Second Line	:	APT 1
City	:	FLUSHING
State	:	NY
Zip	:	11367-3937
Country	:	US
Telephone Number	:	718-591-1600
Fax Number	:	718-591-0265

Provider Business Practice Location Address
First Line	:	7935 153RD ST
Second Line	:	APT 1
City	:	FLUSHING
State	:	NY
Zip	:	11367-3937
Country	:	US
Telephone Number	:	718-591-1600
Fax Number	:	718-591-0265

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. EMMANUEL OLUSEGUN FASHAKIN
Credential	:	MD
Telephone Number	:	718-591-1600

Provider Enumeration Date	:	10/11/2011
Last Update Date	:	10/11/2011

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