MEDICARE: AMANDA PIDGEON 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	363AS0400X	Surgical Physician Assistant	010224	NY

General Provider Information

NPI Number	:	1437191715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA PIDGEON RPAC

Provider Business Mailing Address
First Line	:	STONY BROOK UNIVERSITY MEDICAL CTR
Second Line	:	HSC LEVEL 12, RM 080
City	:	STONY BROOK
State	:	NY
Zip	:	11794-8122
Country	:	US
Telephone Number	:	631-444-1116
Fax Number	:	631-444-1535

Provider Business Practice Location Address
First Line	:	STONY BROOK UNIVERSITY MEDICAL CTR
Second Line	:	HSC LEVEL 12, RM 080
City	:	STONY BROOK
State	:	NY
Zip	:	11794-8122
Country	:	US
Telephone Number	:	631-444-1116
Fax Number	:	631-444-1535

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

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	07/08/2007

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