Provider Demographics
NPI:1801891064
Name:OCEAN PARKWAY MEDICAL, P.C.
Entity type:Organization
Organization Name:OCEAN PARKWAY MEDICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERNAML MEDICINE/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TATYANA
Authorized Official - Middle Name:
Authorized Official - Last Name:INGBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-724-0900
Mailing Address - Street 1:749 OCEAN PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-7813
Mailing Address - Country:US
Mailing Address - Phone:718-724-0900
Mailing Address - Fax:718-724-1590
Practice Address - Street 1:749 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-7813
Practice Address - Country:US
Practice Address - Phone:718-724-0900
Practice Address - Fax:718-724-1590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205927207Q00000X
NYN005775213E00000X
NY200551207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02357775Medicaid
NYWEG681Medicare PIN