Provider Demographics
NPI:1245756733
Name:MGK INC
Entity Type:Organization
Organization Name:MGK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:KUDRENETSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MSED
Authorized Official - Phone:917-504-2705
Mailing Address - Street 1:PO BOX 716
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-0701
Mailing Address - Country:US
Mailing Address - Phone:917-504-2705
Mailing Address - Fax:
Practice Address - Street 1:66 SUMMER ST UNIT 311
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-2316
Practice Address - Country:US
Practice Address - Phone:917-504-2705
Practice Address - Fax:203-428-6200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-17
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129466689252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1164853842Medicaid