Provider Demographics
NPI:1720170087
Name:KINGSBORO PSYCHIATRIC CENTER
Entity type:Organization
Organization Name:KINGSBORO PSYCHIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTENDING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DASEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRAJKOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-221-7391
Mailing Address - Street 1:24 LAUREL AVENUE
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670
Mailing Address - Country:US
Mailing Address - Phone:201-568-5395
Mailing Address - Fax:
Practice Address - Street 1:24 LAUREL AVENUE
Practice Address - Street 2:
Practice Address - City:TENAFLY
Practice Address - State:NJ
Practice Address - Zip Code:07670
Practice Address - Country:US
Practice Address - Phone:201-568-5395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
090BP1Medicare ID - Type Unspecified
H67132Medicare UPIN
NY02415130Medicare ID - Type Unspecified