Provider Demographics
NPI:1477996353
Name:BROCKPORT MEDICAL CARE PLLC
Entity Type:Organization
Organization Name:BROCKPORT MEDICAL CARE PLLC
Other - Org Name:BROCKPORT ASAP MEDICAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HANY
Authorized Official - Middle Name:G
Authorized Official - Last Name:NISSIEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-637-7006
Mailing Address - Street 1:6565 4TH SECTION RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-2414
Mailing Address - Country:US
Mailing Address - Phone:585-395-0620
Mailing Address - Fax:585-395-0622
Practice Address - Street 1:6565 4TH SECTION RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-2414
Practice Address - Country:US
Practice Address - Phone:585-637-7006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY227675261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care