Provider Demographics
NPI:1679670210
Name:INTERBORO SURGICAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:INTERBORO SURGICAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BREVETTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-748-0500
Mailing Address - Street 1:8318 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-4413
Mailing Address - Country:US
Mailing Address - Phone:718-748-0500
Mailing Address - Fax:718-748-5539
Practice Address - Street 1:8318 4TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-4413
Practice Address - Country:US
Practice Address - Phone:718-748-0500
Practice Address - Fax:718-748-5539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222936208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty