Provider Demographics
NPI:1174539829
Name:BROOKLYN 83RD ST MEDICAL
Entity type:Organization
Organization Name:BROOKLYN 83RD ST MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:H
Authorized Official - Last Name:SOLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-531-2500
Mailing Address - Street 1:657-659 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002
Mailing Address - Country:US
Mailing Address - Phone:201-437-3007
Mailing Address - Fax:201-437-4070
Practice Address - Street 1:763 E 83RD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236
Practice Address - Country:US
Practice Address - Phone:718-531-2500
Practice Address - Fax:718-531-2552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01566581Medicaid
NYW24941Medicare ID - Type Unspecified