MEDICARE: MOUSTAFA AHMED FARAGALLAH PT

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	208100000X	Physical Medicine & Rehabilitation Physician	014922	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	014922	OTHER	NY	014922

General Provider Information

NPI Number	:	1740455856
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOUSTAFA AHMED FARAGALLAH PT

Provider Business Mailing Address
First Line	:	2055 60TH ST APT 4
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-2434
Country	:	US
Telephone Number	:	718-331-6323
Fax Number	:

Provider Business Practice Location Address
First Line	:	2055 60TH ST APT 4
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-2434
Country	:	US
Telephone Number	:	718-331-6323
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2008
Last Update Date	:	04/29/2008

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