Basic Information
| Provider Information | |||||||||
| NPI: | 1538106976 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STOCKHOLM OBSTETRICS & GYNECOLOGICAL SERVICES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 374 STOCKHOLM ST | ||||||||
| Address2: | WYCKOFF HEIGHTS MEDICAL CENTER - FACULTY PRACTICE | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112374006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189636485 | ||||||||
| FaxNumber: | 7189636793 | ||||||||
| Practice Location | |||||||||
| Address1: | 374 STOCKHOLM ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112374006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189637272 | ||||||||
| FaxNumber: | 7189636793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 04/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | RUGGIERO | ||||||||
| AuthorizedOfficialFirstName: | RALPH | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7189636485 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Midwife | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 03299956 | 05 | NY | MEDICAID |