MEDICARE: XINGONG GAO LAC PT DPT

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	171100000X	Acupuncturist	002222 1	NY
2	225100000X	Physical Therapist	013918 1	NY

General Provider Information

NPI Number	:	1013998962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	XINGONG GAO LAC PT DPT

Provider Business Mailing Address
First Line	:	401 BROADWAY
Second Line	:	STE 709
City	:	NEW YORK
State	:	NY
Zip	:	10013-3018
Country	:	US
Telephone Number	:	212-625-9290
Fax Number	:	212-925-3101

Provider Business Practice Location Address
First Line	:	401 BROADWAY
Second Line	:	STE 709
City	:	NEW YORK
State	:	NY
Zip	:	10013-3018
Country	:	US
Telephone Number	:	212-625-9290
Fax Number	:	212-925-3101

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2005
Last Update Date	:	07/09/2010

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