MEDICARE: HALE I PERLMUTTER RPAC

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	363A00000X	Physician Assistant	2797	CT
2	363A00000X	Physician Assistant	12421	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00027074	OTHER		RAILROAD MEDICARE

General Provider Information

NPI Number	:	1417942202
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HALE I PERLMUTTER RPAC

Provider Business Mailing Address
First Line	:	1400 PELHAM PKWY S
Second Line	:	BUILDING 1 PSYCHIATRY
City	:	BRONX
State	:	NY
Zip	:	10461-1138
Country	:	US
Telephone Number	:	718-918-6739
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 PELHAM PKWY S
Second Line	:	BUILDING 1 PSYCHIATRY
City	:	BRONX
State	:	NY
Zip	:	10461-1138
Country	:	US
Telephone Number	:	718-918-6739
Fax Number	:

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

Provider Enumeration Date	:	09/16/2005
Last Update Date	:	01/15/2015

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