Provider Demographics
NPI:1184750564
Name:SHEEPSHEAD BAY MEDICAL ASSOCIATES, PC
Entity type:Organization
Organization Name:SHEEPSHEAD BAY MEDICAL ASSOCIATES, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:MANNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-615-0162
Mailing Address - Street 1:3632 NOSTRAND AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-5308
Mailing Address - Country:US
Mailing Address - Phone:718-615-0162
Mailing Address - Fax:718-934-1324
Practice Address - Street 1:2912 AVENUE X
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-1906
Practice Address - Country:US
Practice Address - Phone:718-615-0162
Practice Address - Fax:718-934-1324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1184750564Medicaid