MEDICARE: NANA JINJOLAVA M.D.

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	271592	NY

General Provider Information

NPI Number	:	1205172061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANA JINJOLAVA M.D.

Provider Business Mailing Address
First Line	:	326 E 149TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10451-5602
Country	:	US
Telephone Number	:	718-585-6100
Fax Number	:	718-402-5034

Provider Business Practice Location Address
First Line	:	326 E 149TH ST
Second Line	:	SOUTHERN MEDICAL GROUP
City	:	BRONX
State	:	NY
Zip	:	10451-5602
Country	:	US
Telephone Number	:	718-585-6100
Fax Number	:	718-402-5034

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

Provider Enumeration Date	:	12/26/2012
Last Update Date	:	01/13/2017

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