MEDICARE: BROOKLYN AVENUE MEDICAL PLLC

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	207L00000X	Anesthesiology Physician

General Provider Information

NPI Number	:	1942686951
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKLYN AVENUE MEDICAL PLLC

Provider Business Mailing Address
First Line	:	200 BROOKLYN AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11213-1908
Country	:	US
Telephone Number	:	718-498-7888
Fax Number	:	718-604-7890

Provider Business Practice Location Address
First Line	:	200 BROOKLYN AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11213-1908
Country	:	US
Telephone Number	:	718-498-7888
Fax Number	:	718-604-7890

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. SHELBY KEVIN SAMUEL
Credential	:	M.D.
Telephone Number	:	718-498-7888

Provider Enumeration Date	:	08/03/2015
Last Update Date	:	08/03/2015

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