Provider Demographics
NPI:1558394320
Name:BROUKHIM, MARYAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:BROUKHIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 NORTHERN BLVD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5302
Mailing Address - Country:US
Mailing Address - Phone:516-487-3783
Mailing Address - Fax:516-487-1392
Practice Address - Street 1:900 NORTHERN BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5302
Practice Address - Country:US
Practice Address - Phone:516-487-3783
Practice Address - Fax:516-487-1392
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196144174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01573660Medicaid
NY03840AOtherGHI MEDICARE
NY161221Medicare ID - Type Unspecified
NYF48893Medicare UPIN
NY161221Medicare PIN