Provider Demographics
NPI:1124234489
Name:COLLIN EM BRATHWAITE MD PLLC
Entity type:Organization
Organization Name:COLLIN EM BRATHWAITE MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRA CTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-265-7000
Mailing Address - Street 1:48 ROUTE 25A
Mailing Address - Street 2:SUITE LL7
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-1431
Mailing Address - Country:US
Mailing Address - Phone:631-265-7000
Mailing Address - Fax:631-784-7410
Practice Address - Street 1:48 ROUTE 25A
Practice Address - Street 2:SUITE LL7
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-1431
Practice Address - Country:US
Practice Address - Phone:631-265-7000
Practice Address - Fax:631-784-7410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211561208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWET971Medicare ID - Type Unspecified