MEDICARE: BROOKLYN MEDICAL ASSOCIATES, 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	207Q00000X	Family Medicine Physician	50000594A	IN

General Provider Information

NPI Number	:	1851512198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKLYN MEDICAL ASSOCIATES, PC

Provider Business Mailing Address
First Line	:	3534 BROOKLYN AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46809-1361
Country	:	US
Telephone Number	:	260-747-6171
Fax Number	:	260-478-5125

Provider Business Practice Location Address
First Line	:	5717 S ANTHONY BLVD
Second Line	:	SUITE 100
City	:	FORT WAYNE
State	:	IN
Zip	:	46806-3386
Country	:	US
Telephone Number	:	260-747-6171
Fax Number	:	260-478-5125

Authorized Official
Title or Position	:	CEO
Name	:	BILL EHINGER
Credential	:
Telephone Number	:	260-478-5226

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	11/06/2007

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