Provider Demographics
NPI:1194746636
Name:RUTLAND MEDICAL PLAZA
Entity type:Organization
Organization Name:RUTLAND MEDICAL PLAZA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:OKECHUKWU
Authorized Official - Last Name:EZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-652-6797
Mailing Address - Street 1:3 NORMAN CT
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-5811
Mailing Address - Country:US
Mailing Address - Phone:631-423-2397
Mailing Address - Fax:631-643-5409
Practice Address - Street 1:887 RUTLAND RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203
Practice Address - Country:US
Practice Address - Phone:718-756-3918
Practice Address - Fax:718-756-1684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200487207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01623665Medicaid
NY7838Medicare UPIN
NY01623665Medicaid