MEDICARE: MANHATTAN AVENUE MEDICAL PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	130554	NY

General Provider Information

NPI Number	:	1013217629
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANHATTAN AVENUE MEDICAL PC

Provider Business Mailing Address
First Line	:	552 EAST 180TH STREET
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10457-3304
Country	:	US
Telephone Number	:	718-933-4445
Fax Number	:	718-933-4444

Provider Business Practice Location Address
First Line	:	552 EAST 180TH STREET
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10457-3304
Country	:	US
Telephone Number	:	718-933-4445
Fax Number	:	718-933-4444

Authorized Official
Title or Position	:	OWNER
Name	:	DR. AZU A AJUDUA
Credential	:
Telephone Number	:	718-933-4445

Provider Enumeration Date	:	10/28/2010
Last Update Date	:	09/11/2012

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