MEDICARE: ST. MARKS MEDICAL, P.C.

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	173000000X	Legal Medicine	143801	NY

General Provider Information

NPI Number	:	1881910305
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. MARKS MEDICAL, P.C.

Provider Business Mailing Address
First Line	:	907 SAINT MARKS AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11213-2004
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	907 SAINT MARKS AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11213-2004
Country	:	US
Telephone Number	:	718-756-6200
Fax Number	:

Authorized Official
Title or Position	:	MD
Name	:	ANDREW D BLACK
Credential	:
Telephone Number	:	718-756-6200

Provider Enumeration Date	:	04/08/2010
Last Update Date	:	04/08/2010

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