Provider Demographics
NPI:1417132390
Name:KINGSBROOK PRACTICE PLAN
Entity Type:Organization
Organization Name:KINGSBROOK PRACTICE PLAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:K
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-563-2497
Mailing Address - Street 1:158 W 27TH ST
Mailing Address - Street 2:11TH FL S
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-6216
Mailing Address - Country:US
Mailing Address - Phone:212-563-2497
Mailing Address - Fax:
Practice Address - Street 1:585 SCHENECTADY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-1809
Practice Address - Country:US
Practice Address - Phone:212-563-2497
Practice Address - Fax:212-563-0605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty