Provider Demographics
NPI:1649429929
Name:OFFICE BASED SURGERY ON THE BAY
Entity type:Organization
Organization Name:OFFICE BASED SURGERY ON THE BAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTNIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-332-5678
Mailing Address - Street 1:1711 SHEEPSHEAD BAY RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3651
Mailing Address - Country:US
Mailing Address - Phone:718-332-5678
Mailing Address - Fax:718-934-1780
Practice Address - Street 1:1711 SHEEPSHEAD BAY RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3651
Practice Address - Country:US
Practice Address - Phone:718-332-5678
Practice Address - Fax:718-934-1780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A63833Medicare UPIN