Provider Demographics
NPI: | 1952612426 |
---|---|
Name: | BROOKLYN MEDICAL ASSOCIATES, PC |
Entity Type: | Organization |
Organization Name: | BROOKLYN MEDICAL ASSOCIATES, PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | BILL |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | EHINGER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 260-478-5226 |
Mailing Address - Street 1: | 3534 BROOKLYN AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | FORT WAYNE |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46809-1361 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 260-747-6171 |
Mailing Address - Fax: | 260-478-5125 |
Practice Address - Street 1: | 1302 MINNICH RD |
Practice Address - Street 2: | |
Practice Address - City: | NEW HAVEN |
Practice Address - State: | IN |
Practice Address - Zip Code: | 46774-2052 |
Practice Address - Country: | US |
Practice Address - Phone: | 260-747-6171 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-06-29 |
Last Update Date: | 2010-06-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 50000594A | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Single Specialty |