Provider Demographics
NPI:1285952804
Name:MMC PLASTIC SURGERY FPP
Entity type:Organization
Organization Name:MMC PLASTIC SURGERY FPP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF, PLASTIC SURGERY
Authorized Official - Prefix:DR
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:B
Authorized Official - Last Name:GAYLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-765-2570
Mailing Address - Street 1:PO BOX 30074
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-0074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:745 64TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-4745
Practice Address - Country:US
Practice Address - Phone:718-765-2570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAIMONIDES MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-06
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01361999Medicaid
NY01361999Medicaid
NY21I671Medicare PIN