MEDICARE: TRISTATE MEDICAL CARE 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	207R00000X	Internal Medicine Physician	128754	NY
2	261QP2300X	Primary Care Clinic/Center	128754	NY
3	261QP2300X	Primary Care Clinic/Center	25MA06036700	NJ
4	207RC0000X	Cardiovascular Disease Physician	128754	NY

General Provider Information

NPI Number	:	1972693315
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRISTATE MEDICAL CARE PC

Provider Business Mailing Address
First Line	:	8200 21ST AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214
Country	:	US
Telephone Number	:	718-236-6644
Fax Number	:	718-236-9080

Provider Business Practice Location Address
First Line	:	3615 AVE S
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234
Country	:	US
Telephone Number	:	718-336-2110
Fax Number	:

Authorized Official
Title or Position	:	MD FACP FACC
Name	:	DR. SHASHIBALA SONI
Credential	:
Telephone Number	:	718-236-4444

Provider Enumeration Date	:	10/14/2006
Last Update Date	:	01/16/2008

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