MEDICARE: LIONDALE MANAGEMENT INC

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	208D00000X	General Practice Physician	193423	NY

General Provider Information

NPI Number	:	1013291293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIONDALE MANAGEMENT INC

Provider Business Mailing Address
First Line	:	10 W 74TH ST APT 1D
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10023-2404
Country	:	US
Telephone Number	:	212-579-9136
Fax Number	:	212-579-6917

Provider Business Practice Location Address
First Line	:	10 W 74TH ST APT 1D
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10023-2404
Country	:	US
Telephone Number	:	212-579-9136
Fax Number	:	212-579-6917

Authorized Official
Title or Position	:	PROVIDER
Name	:	LIONELL BISSOON
Credential	:	DO
Telephone Number	:	212-579-9136

Provider Enumeration Date	:	10/05/2011
Last Update Date	:	10/05/2011

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