Provider Demographics
NPI:1346883774
Name:BRIGHTON MEDICAL PRACTICE P.C.
Entity Type:Organization
Organization Name:BRIGHTON MEDICAL PRACTICE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHILA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOMTAJ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-368-3092
Mailing Address - Street 1:706 BANNER AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-6957
Mailing Address - Country:US
Mailing Address - Phone:718-368-3092
Mailing Address - Fax:718-368-2051
Practice Address - Street 1:706 BANNER AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6957
Practice Address - Country:US
Practice Address - Phone:718-368-3092
Practice Address - Fax:718-368-2051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-17
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02743364Medicaid