Provider Demographics
NPI:1083785083
Name:INTERCOUNTY OBGYN
Entity Type:Organization
Organization Name:INTERCOUNTY OBGYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BALA
Authorized Official - Middle Name:KB
Authorized Official - Last Name:RAVI
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:718-497-3121
Mailing Address - Street 1:PO BOX 370508
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237
Mailing Address - Country:US
Mailing Address - Phone:718-497-3121
Mailing Address - Fax:718-497-3126
Practice Address - Street 1:6608 FRESH POND ROAD
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385
Practice Address - Country:US
Practice Address - Phone:718-497-3045
Practice Address - Fax:718-497-3126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203725207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G34489Medicare UPIN
NY32G561Medicare ID - Type Unspecified