Provider Demographics
NPI:1407080880
Name:BAY 29 MEDICAL PC
Entity Type:Organization
Organization Name:BAY 29 MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHITRE
Authorized Official - Middle Name:NITIN
Authorized Official - Last Name:PRABHAKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-758-4520
Mailing Address - Street 1:174 BAY 29TH STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214
Mailing Address - Country:US
Mailing Address - Phone:718-758-4520
Mailing Address - Fax:
Practice Address - Street 1:174 BAY 29TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-5020
Practice Address - Country:US
Practice Address - Phone:718-758-4520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2002782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty