Basic Information
| Provider Information | |||||||||
| NPI: | 1114320397 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | M2 MEDICAL COMMUNITY PRACTICE, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4802 10TH AVE | ||||||||
| Address2: | EXECUTIVE OFFICE | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112192916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182836392 | ||||||||
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| Address1: | 4802 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112192916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182836000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2014 | ||||||||
| LastUpdateDate: | 10/02/2014 | ||||||||
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| AuthorizedOfficialLastName: | COHEN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP | ||||||||
| AuthorizedOfficialTelephone: | 7182836392 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.