Provider Demographics
NPI:1194096404
Name:JACK JEDWAB MD PC
Entity type:Organization
Organization Name:JACK JEDWAB MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:JEDWAB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-377-7575
Mailing Address - Street 1:2270 KIMBALL ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5139
Mailing Address - Country:US
Mailing Address - Phone:718-377-7575
Mailing Address - Fax:
Practice Address - Street 1:2270 KIMBALL ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-5139
Practice Address - Country:US
Practice Address - Phone:718-377-7575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139976208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY27A801Medicare PIN