Provider Demographics
NPI:1902004484
Name:FAMILY MEDICAL CARE OF MARINE PARK, P.C.
Entity Type:Organization
Organization Name:FAMILY MEDICAL CARE OF MARINE PARK, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-998-9669
Mailing Address - Street 1:2915 AVENUE S
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229
Mailing Address - Country:US
Mailing Address - Phone:718-998-9669
Mailing Address - Fax:718-339-5614
Practice Address - Street 1:2915 AVENUE S
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-2544
Practice Address - Country:US
Practice Address - Phone:718-998-9669
Practice Address - Fax:718-339-5614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEX651Medicare PIN