Provider Demographics
NPI:1598878167
Name:FAITH FAMILY MEDICAL PC
Entity type:Organization
Organization Name:FAITH FAMILY MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN-ETIENNE
Authorized Official - Middle Name:
Authorized Official - Last Name:THIBAUD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:718-531-6100
Mailing Address - Street 1:PO BOX 100714
Mailing Address - Street 2:VANDERVEER STATION
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-0714
Mailing Address - Country:US
Mailing Address - Phone:718-531-6100
Mailing Address - Fax:718-531-2329
Practice Address - Street 1:1713-19 RALPH AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236
Practice Address - Country:US
Practice Address - Phone:718-531-6100
Practice Address - Fax:718-531-2329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224277207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty