MEDICARE: IM PRIMARY MEDICAL CARE , 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	207VG0400X	Gynecology Physician	254486	NY
2	207VX0000X	Obstetrics Physician	254486	NY
3	207V00000X	Obstetrics & Gynecology Physician	254486	NY

General Provider Information

NPI Number	:	1619250073
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IM PRIMARY MEDICAL CARE , PC

Provider Business Mailing Address
First Line	:	900 LENOX RD
Second Line	:	SUITE 1
City	:	BROOKLYN
State	:	NY
Zip	:	11203-2603
Country	:	US
Telephone Number	:	718-485-5500
Fax Number	:

Provider Business Practice Location Address
First Line	:	900 LENOX RD
Second Line	:	SUITE 1
City	:	BROOKLYN
State	:	NY
Zip	:	11203-2603
Country	:	US
Telephone Number	:	718-485-5500
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	IRINA MIKHEYEVA
Credential	:	D.O.
Telephone Number	:	718-485-5500

Provider Enumeration Date	:	09/22/2011
Last Update Date	:	09/22/2011

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