Provider Demographics
NPI:1073835641
Name:BLUE GREEN HORIZONS OFFICE BASED SURGERY PLLC
Entity Type:Organization
Organization Name:BLUE GREEN HORIZONS OFFICE BASED SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:K
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-498-7888
Mailing Address - Street 1:200 BROOKLYN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-1908
Mailing Address - Country:US
Mailing Address - Phone:718-498-7888
Mailing Address - Fax:718-604-7890
Practice Address - Street 1:200 BROOKLYN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-1908
Practice Address - Country:US
Practice Address - Phone:718-498-7888
Practice Address - Fax:718-604-7890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176352261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty