Provider Demographics
NPI:1285465989
Name:RUSHING WATERS MEDICAL, PLLC
Entity type:Organization
Organization Name:RUSHING WATERS MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TANYKA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-588-4798
Mailing Address - Street 1:726 UTICA AVE UNIT 30068
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2267
Mailing Address - Country:US
Mailing Address - Phone:917-588-4798
Mailing Address - Fax:
Practice Address - Street 1:1530 BEDFORD AVE FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-4117
Practice Address - Country:US
Practice Address - Phone:917-588-4798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-13
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty