MEDICARE: SEAGULL MEDICAL SERVICES

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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1770051690
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEAGULL MEDICAL SERVICES

Provider Business Mailing Address
First Line	:	368 77TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-3110
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 NORWALK AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-5658
Country	:	US
Telephone Number	:	929-574-1629
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ILYA SMUGLIN
Credential	:	MD
Telephone Number	:	929-327-2566

Provider Enumeration Date	:	11/08/2018
Last Update Date	:	11/15/2018

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