MEDICARE: SOUTH BROOKLYN MEDICAL 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	174400000X	Specialist	218261	NY

General Provider Information

NPI Number	:	1639575665
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH BROOKLYN MEDICAL PC

Provider Business Mailing Address
First Line	:	2119 E 15TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-4314
Country	:	US
Telephone Number	:	718-975-2709
Fax Number	:	718-975-2709

Provider Business Practice Location Address
First Line	:	2119 E 15TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-4314
Country	:	US
Telephone Number	:	718-975-2709
Fax Number	:	718-975-2709

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GRIGORY SHTENDER
Credential	:	MD
Telephone Number	:	718-975-2709

Provider Enumeration Date	:	11/19/2014
Last Update Date	:	11/19/2014

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