Provider Demographics
NPI:1598945032
Name:BORO PARK PRIMARY MEDICAL PLLC
Entity Type:Organization
Organization Name:BORO PARK PRIMARY MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STUIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDWASSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-431-9870
Mailing Address - Street 1:1153 58TH STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1153 58TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-4526
Practice Address - Country:US
Practice Address - Phone:718-431-9870
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEZ951Medicare PIN