Provider Demographics
NPI:1982949624
Name:MEDICAL CARE OF KINGSBOROUGH PC
Entity type:Organization
Organization Name:MEDICAL CARE OF KINGSBOROUGH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EWALD
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTOINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-513-6440
Mailing Address - Street 1:2297 CONEY ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-3337
Mailing Address - Country:US
Mailing Address - Phone:718-513-6440
Mailing Address - Fax:718-975-2085
Practice Address - Street 1:2297 CONEY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-3337
Practice Address - Country:US
Practice Address - Phone:718-513-6440
Practice Address - Fax:718-975-2085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01644706Medicaid
167153OtherLICENSE