Provider Demographics
NPI:1164454658
Name:MILL BASIN MEDICAL SERVICES PC
Entity Type:Organization
Organization Name:MILL BASIN MEDICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:COREY
Authorized Official - Middle Name:
Authorized Official - Last Name:KORBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-644-9276
Mailing Address - Street 1:3915 AVENUE V
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5156
Mailing Address - Country:US
Mailing Address - Phone:718-252-8440
Mailing Address - Fax:
Practice Address - Street 1:222 BLOOMINGDALE RD
Practice Address - Street 2:SUITE 400
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-1513
Practice Address - Country:US
Practice Address - Phone:914-644-9276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00725457Medicaid
NY00725457Medicaid