Provider Demographics
NPI:1225199789
Name:WOODBINE MEDICAL PC
Entity Type:Organization
Organization Name:WOODBINE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CARMILI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-418-5320
Mailing Address - Street 1:714 SENECA AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-2895
Mailing Address - Country:US
Mailing Address - Phone:718-418-5320
Mailing Address - Fax:
Practice Address - Street 1:714 SENECA AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-2895
Practice Address - Country:US
Practice Address - Phone:718-418-5320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022692174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02632117Medicaid
NY02632117Medicaid
NY02632117Medicare ID - Type Unspecified