Provider Demographics
NPI:1366567414
Name:ADULT AND GERIATRIC MEDICAL CARE PC
Entity type:Organization
Organization Name:ADULT AND GERIATRIC MEDICAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-609-5537
Mailing Address - Street 1:157 BEAUMONT ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-4118
Mailing Address - Country:US
Mailing Address - Phone:917-609-4748
Mailing Address - Fax:718-630-3761
Practice Address - Street 1:4802 10TH AVE FL 10
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2916
Practice Address - Country:US
Practice Address - Phone:917-609-5537
Practice Address - Fax:718-630-3761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234232261Q00000X
207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03416084Medicaid
NY177SD1Medicare ID - Type Unspecified
NY02702376Medicaid