Provider Demographics
NPI:1104634773
Name:SUITE 69 MEDICAL PC
Entity type:Organization
Organization Name:SUITE 69 MEDICAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:TERRY-JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKETT-BONNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-404-6508
Mailing Address - Street 1:275 9TH ST STE 69
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-4457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:275 9TH ST STE 69
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-4457
Practice Address - Country:US
Practice Address - Phone:347-404-6508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-27
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty