Provider Demographics
NPI:1508133232
Name:ORIGINAL CARE MEDICAL PC
Entity Type:Organization
Organization Name:ORIGINAL CARE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-775-5960
Mailing Address - Street 1:333 GREENE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-2295
Mailing Address - Country:US
Mailing Address - Phone:718-758-5777
Mailing Address - Fax:888-887-9723
Practice Address - Street 1:333 GREENE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-2295
Practice Address - Country:US
Practice Address - Phone:718-758-5777
Practice Address - Fax:888-887-9723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY259336261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty