Provider Demographics
NPI:1386951762
Name:CONEY ISLAND MEDICAL PRACTICE PLAN, P.C.
Entity type:Organization
Organization Name:CONEY ISLAND MEDICAL PRACTICE PLAN, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUDHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PENTYALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-675-9300
Mailing Address - Street 1:234 E 149TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-5504
Mailing Address - Country:US
Mailing Address - Phone:718-579-6017
Mailing Address - Fax:718-579-6060
Practice Address - Street 1:2601 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7745
Practice Address - Country:US
Practice Address - Phone:718-616-5354
Practice Address - Fax:718-579-6060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-08
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty