Provider Demographics
NPI:1295918167
Name:ADVANCED MEDICAL OF GRAND CENTRAL PC
Entity type:Organization
Organization Name:ADVANCED MEDICAL OF GRAND CENTRAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASHENSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-401-8476
Mailing Address - Street 1:1003 HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3013
Mailing Address - Country:US
Mailing Address - Phone:347-401-8476
Mailing Address - Fax:
Practice Address - Street 1:50 E 42ND ST
Practice Address - Street 2:STE 200
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-5405
Practice Address - Country:US
Practice Address - Phone:212-867-0405
Practice Address - Fax:212-867-0409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWZT6Z1Medicare PIN