MEDICARE: MMC DIVISION OF BREAST SURGERY

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	208600000X	Surgery Physician

General Provider Information

NPI Number	:	1609980846
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MMC DIVISION OF BREAST SURGERY

Provider Business Mailing Address
First Line	:	6300 8TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-4718
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	745 64TH ST STE 1
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-4753
Country	:	US
Telephone Number	:	718-765-2570
Fax Number	:	718-765-2569

Authorized Official
Title or Position	:	DEPARTMENT HEAD
Name	:	CHARUSHEELA ANDAZ
Credential	:	MD
Telephone Number	:	718-283-8773

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	09/16/2024

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