Provider Demographics
NPI:1477888980
Name:BROOKLYN SELECT PHYSICIAN
Entity Type:Organization
Organization Name:BROOKLYN SELECT PHYSICIAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SAMIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYAB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-622-2300
Mailing Address - Street 1:1236 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-2093
Mailing Address - Country:US
Mailing Address - Phone:718-622-2300
Mailing Address - Fax:718-622-2323
Practice Address - Street 1:1236 FULTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-2093
Practice Address - Country:US
Practice Address - Phone:718-622-2300
Practice Address - Fax:718-622-2323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217560261Q00000X
NY212345261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center