MEDICARE: RODAINA MUSALLAM

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1508120254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RODAINA MUSALLAM

Provider Business Mailing Address
First Line	:	2680 FORD ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-1307
Country	:	US
Telephone Number	:	347-249-8299
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 CONEY ISLAND AVE STE 4
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-2343
Country	:	US
Telephone Number	:	718-434-1012
Fax Number	:

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

Provider Enumeration Date	:	06/27/2012
Last Update Date	:	06/27/2012

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