Provider Demographics
NPI:1790960839
Name:BROOME SURGERY & BREAST CARE, P.C.
Entity Type:Organization
Organization Name:BROOME SURGERY & BREAST CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GHASSEM
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGOURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-729-0443
Mailing Address - Street 1:240 RIVERSIDE DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2732
Mailing Address - Country:US
Mailing Address - Phone:607-729-0443
Mailing Address - Fax:607-766-9395
Practice Address - Street 1:240 RIVERSIDE DR
Practice Address - Street 2:SUITE 3
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2732
Practice Address - Country:US
Practice Address - Phone:607-729-0443
Practice Address - Fax:607-766-9395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0154223174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00775599Medicaid
NY00775599Medicaid