Promed Preferred PA 5 Professional Corporation
Organization Active NPI Internal Medicine Physician · Brooklyn, NY
NPI 1053200410 · NPPES record last updated Jul 1, 2025
Key facts
- NPI
- 1053200410
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Internal Medicine Physician 207R00000X
- Legal business name
- PROMED PREFERRED PA 5 PROFESSIONAL CORPORATION
- Practice address
- 1314 54TH St
Brooklyn, NY 11219-4219 - Phone
- (615) 499-3165
- NPI assigned
- Jul 1, 2025
- Organization subpart
- No
Authorized official
- Name
- Lev Grinman, MD
- Title
- President
- Phone
- (615) 499-3165
Practitioners 7
-
Jennifer Clerisson, NURSE PRACTITIONER
-
Kelly Ann Shearer, MSN, AGNP-C
-
Leanne Malka Feibush, APRN
-
Katouchca Michel, FNP
-
Megan Ryan-Riffle, CRNP
-
Frank Suppa, D.O
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in PA
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20250801000849 | PA | Part B Supplier - Clinic/Group Practice | 2769990761 |
Receives reassigned benefits from 6 practitioners Practice locations: State College, PA |
National Provider Directory
Locations
4640 E Roosevelt Blvd
Ste 3
Philadelphia, PA 19124
Phone (215) 315-1414
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician |
207R00000X | Yes |
Addresses
Primary practice location
1314 54TH St
Brooklyn, NY 11219-4219
Mailing address
329 S Oyster Bay Rd # 2059
Plainview, NY 11803-3301
Other providers in Brooklyn, NY
- Promed
- Promed Personnel Service
- Promed Personnel Services
- Promed Personnel Services
- Promed Preferred de, P.a.
- Promed Preferred TX 5, PLLC
- Promed Preferred VA Professional Corporation
- Promed Preferred WV Professional Corporation
- Promeda Medical and Diagnostics, P.C.
- Prominis Medical Services PC
All providers in Brooklyn, NY · Internal Medicine Physician in New York
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 1, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.