MEDICARE: SRB PLASTIC SURGERY 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	208200000X	Plastic Surgery Physician	166718	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0100923	OTHER	NY	GHI
2	N37868	OTHER	NY	HEALTH NET
3	80H671	OTHER	NY	BLUE CROSS BLUE SHIELD
4	P3806444	OTHER	NY	OXFORD

General Provider Information

NPI Number	:	1962612507
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SRB PLASTIC SURGERY PC

Provider Business Mailing Address
First Line	:	SRB PLASTIC SURGERY PC
Second Line	:	75 E 71ST STREET
City	:	NEW YORK
State	:	NY
Zip	:	10021-4251
Country	:	US
Telephone Number	:	212-879-7900
Fax Number	:

Provider Business Practice Location Address
First Line	:	740 PARK AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10021-4251
Country	:	US
Telephone Number	:	212-879-7900
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STAFFORD R BROUMAND
Credential	:	M.D.
Telephone Number	:	212-879-7900

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	06/16/2018

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