Provider Demographics
NPI:1497838114
Name:MMC DIVISION OF NEUROLOGY FPP
Entity Type:Organization
Organization Name:MMC DIVISION OF NEUROLOGY FPP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NEUROLOGY
Authorized Official - Prefix:
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:
Authorized Official - Last Name:KEILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-283-5858
Mailing Address - Street 1:883 65TH STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220
Mailing Address - Country:US
Mailing Address - Phone:718-283-7470
Mailing Address - Fax:718-635-6082
Practice Address - Street 1:883 65TH STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220
Practice Address - Country:US
Practice Address - Phone:718-283-7470
Practice Address - Fax:718-635-6082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WES861Medicare PIN