Provider Demographics
NPI:1417012568
Name:BRENTWOOD MEDICAL CARE, PC
Entity type:Organization
Organization Name:BRENTWOOD MEDICAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:VISO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:631-751-5588
Mailing Address - Street 1:1890 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-2904
Mailing Address - Country:US
Mailing Address - Phone:631-427-6920
Mailing Address - Fax:
Practice Address - Street 1:55 SECOND AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4611
Practice Address - Country:US
Practice Address - Phone:631-751-5588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183817208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty