MEDICARE: PATHWAYS MEDICAL PLLC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1285314609
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATHWAYS MEDICAL PLLC

Provider Business Mailing Address
First Line	:	111 W 110TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10026-4281
Country	:	US
Telephone Number	:	212-856-2740
Fax Number	:	212-537-6414

Provider Business Practice Location Address
First Line	:	111 W 110TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10026-4281
Country	:	US
Telephone Number	:	212-856-2740
Fax Number	:	212-537-6414

Authorized Official
Title or Position	:	OWNER
Name	:	DIEGO A PONIEMAN
Credential	:	MD
Telephone Number	:	212-865-2740

Provider Enumeration Date	:	07/20/2023
Last Update Date	:	07/20/2023

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