Provider Demographics
NPI:1174744221
Name:IMAD JOHN BAKOSS
Entity type:Organization
Organization Name:IMAD JOHN BAKOSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IMAD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAKOSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-621-7100
Mailing Address - Street 1:2165 71ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-5526
Mailing Address - Country:US
Mailing Address - Phone:718-621-7100
Mailing Address - Fax:718-621-7103
Practice Address - Street 1:2165 71ST ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-5526
Practice Address - Country:US
Practice Address - Phone:718-621-7100
Practice Address - Fax:718-621-7103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129319202C00000X, 207R00000X, 207RC0200X, 207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical ExaminerGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00271187Medicaid
NY00271187Medicaid
NYA62281Medicare UPIN