Provider Demographics
NPI:1952376642
Name:BOATMAN, BRIAN G (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:G
Last Name:BOATMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 7TH AVENUE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001
Mailing Address - Country:US
Mailing Address - Phone:646-660-9999
Mailing Address - Fax:646-778-3450
Practice Address - Street 1:275 7TH AVENUE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001
Practice Address - Country:US
Practice Address - Phone:646-660-9999
Practice Address - Fax:646-778-3450
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221252207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02654093Medicaid
468Q01Medicare ID - Type Unspecified
NY02654093Medicaid