Provider Demographics
NPI:1841370814
Name:BAY RIDGE FOURTH AVENUE MEDICAL ASSOCIATES, P. C.
Entity type:Organization
Organization Name:BAY RIDGE FOURTH AVENUE MEDICAL ASSOCIATES, P. C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BASTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-748-8282
Mailing Address - Street 1:648 BAY RIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-3330
Mailing Address - Country:US
Mailing Address - Phone:718-748-8282
Mailing Address - Fax:718-836-8113
Practice Address - Street 1:648 BAY RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3330
Practice Address - Country:US
Practice Address - Phone:718-748-8282
Practice Address - Fax:718-836-8113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW1L511Medicare PIN