MEDICARE: EVERGREEN FAMILY MEDICAL SERVICES,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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891761243
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN FAMILY MEDICAL SERVICES,P.C.

Provider Business Mailing Address
First Line	:	743 58TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-3916
Country	:	US
Telephone Number	:	718-765-0088
Fax Number	:	718-567-8208

Provider Business Practice Location Address
First Line	:	743 58TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-3916
Country	:	US
Telephone Number	:	718-765-0088
Fax Number	:	718-567-8208

Authorized Official
Title or Position	:	MEDICAL DIRETOR
Name	:	RAYMOND CHAN
Credential	:	MD
Telephone Number	:	718-765-0088

Provider Enumeration Date	:	02/26/2006
Last Update Date	:	10/01/2012

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