MEDICARE: MRS. CARMEN ENID MEDINA

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	235Z00000X	Speech-Language Pathologist	006423-1	NY

General Provider Information

NPI Number	:	1508169673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CARMEN ENID MEDINA

Provider Business Mailing Address
First Line	:	22 RIVERVIEW AVE
Second Line	:
City	:	ARDSLEY
State	:	NY
Zip	:	10502-2317
Country	:	US
Telephone Number	:	914-693-0149
Fax Number	:

Provider Business Practice Location Address
First Line	:	2340 ANDREWS AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10468-6001
Country	:	US
Telephone Number	:	718-365-7238
Fax Number	:	718-584-3057

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

Provider Enumeration Date	:	12/13/2010
Last Update Date	:	12/13/2010

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Directions to “ MRS. CARMEN ENID MEDINA ” Practice Location

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