MEDICARE: BASHA TEITELBAUM MSED

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	174400000X	Specialist		NY

General Provider Information

NPI Number	:	1912241852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BASHA TEITELBAUM MSED

Provider Business Mailing Address
First Line	:	5614 15TH AVE
Second Line	:	#5F
City	:	BROOKLYN
State	:	NY
Zip	:	11219-4750
Country	:	US
Telephone Number	:	718-853-5126
Fax Number	:	718-514-8693

Provider Business Practice Location Address
First Line	:	5614 15TH AVE
Second Line	:	#5F
City	:	BROOKLYN
State	:	NY
Zip	:	11219-4750
Country	:	US
Telephone Number	:	718-853-5126
Fax Number	:	718-514-8693

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

Provider Enumeration Date	:	11/15/2012
Last Update Date	:	11/15/2012

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Directions to “ BASHA TEITELBAUM MSED” Practice Location

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