Provider Demographics
NPI:1669676466
Name:YEAHSEON BRUININGS MD FAMILY PRACTICE PLLC
Entity Type:Organization
Organization Name:YEAHSEON BRUININGS MD FAMILY PRACTICE PLLC
Other - Org Name:YEAHSEON BRUININGS MD FAM PRACT
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER , PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:YEAHSEON
Authorized Official - Middle Name:CHOI
Authorized Official - Last Name:BRUININGS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-360-5768
Mailing Address - Street 1:3438 BELL BLVD
Mailing Address - Street 2:PH FLOOR 5
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-1730
Mailing Address - Country:US
Mailing Address - Phone:718-360-5768
Mailing Address - Fax:
Practice Address - Street 1:3438 BELL BLVD
Practice Address - Street 2:PH FLOOR 5
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-1730
Practice Address - Country:US
Practice Address - Phone:718-360-5768
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226709207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02405338Medicaid
06630Medicare PIN
NY02405338Medicaid
06630GMedicare PIN