Provider Demographics
NPI:1043428097
Name:GREGORY SUPRIN MD PLLC
Entity type:Organization
Organization Name:GREGORY SUPRIN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUPRIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-498-3103
Mailing Address - Street 1:1381 LINDEN BLVD # B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-4755
Mailing Address - Country:US
Mailing Address - Phone:718-498-3103
Mailing Address - Fax:718-498-3166
Practice Address - Street 1:1381 LINDEN BLVD # B
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-4755
Practice Address - Country:US
Practice Address - Phone:718-498-3103
Practice Address - Fax:718-498-3166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230165207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========OtherTAX IDENTIFICATION