Provider Demographics
NPI:1043232143
Name:GRACE FAMILY MEDICAL PRACTICE PC
Entity Type:Organization
Organization Name:GRACE FAMILY MEDICAL PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:LIZINA
Authorized Official - Last Name:SHERIDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-257-3355
Mailing Address - Street 1:1222 E 96TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-3903
Mailing Address - Country:US
Mailing Address - Phone:718-257-3355
Mailing Address - Fax:718-257-4562
Practice Address - Street 1:1222 E 96TH ST
Practice Address - Street 2:2ND FL
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-3903
Practice Address - Country:US
Practice Address - Phone:718-257-3355
Practice Address - Fax:718-257-4562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149698173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0576775OtherAETNA HMO
NY080412000004OtherFIDELISCARE
NY172447OtherWELLCARE
NY000109940101OtherHEALTH PLUS
NY1P1174OtherHEALTHNET
08P6021OtherNEW YORK PRESBYTERIAN
NY149698OtherHIP
NY5995872OtherGHI
NY03803192Medicaid
NY1043232143OtherHEALTHCARE PARTNERS
NY1043232143OtherEMBLEM HEALTH
NY115438OtherGHI HMO
NY149698-A16OtherHEALTHFIRST
NY311913OtherUNITED HEALTH CARE
NY5760228OtherAETNA COM
NY160955OtherELDER PLAN
NY5462A1OtherEMPIRE BC BS
NYP1078363OtherOXFORD
NY00778863Medicaid
NY0901918OtherCIGNA
NY1000036958OtherAFFINITY
NY160955OtherELDER PLAN
NY0901918OtherCIGNA