MEDICARE: BROOKLYN SELECT PHYSICIAN

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	261Q00000X	Clinic/Center	217560	NY
2	261Q00000X	Clinic/Center	212345	NY

General Provider Information

NPI Number	:	1477888980
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKLYN SELECT PHYSICIAN

Provider Business Mailing Address
First Line	:	1236 FULTON ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11216-2093
Country	:	US
Telephone Number	:	718-622-2300
Fax Number	:	718-622-2323

Provider Business Practice Location Address
First Line	:	1236 FULTON ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11216-2093
Country	:	US
Telephone Number	:	718-622-2300
Fax Number	:	718-622-2323

Authorized Official
Title or Position	:	CEO
Name	:	SAMIA TAYAB
Credential	:	M.D.
Telephone Number	:	718-622-2300

Provider Enumeration Date	:	10/16/2009
Last Update Date	:	10/16/2009

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Directions to “BROOKLYN SELECT PHYSICIAN ” Practice Location

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