Basic Information
| Provider Information | |||||||||
| NPI: | 1205201837 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WYCKOFF PROFESSIONAL MEDICAL SERVICES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 374 STOCKHOLM STREET | ||||||||
| Address2: | WYCKOFF HEIGHTS MEDICAL CENTER - FACULTY PRACTICE | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189637272 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1419 MYRTLE AVE | ||||||||
| Address2: | WYCKOFF DOCTORS | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112374512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187830934 | ||||||||
| FaxNumber: | 7188570162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2015 | ||||||||
| LastUpdateDate: | 06/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | VUTRANO | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7189636702 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WYCKOFF PROFESSIONAL MEDICAL SERVICES PC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 03722025 | 05 | NY | MEDICAID |