MEDICARE: MAXWELL 58 MEDICAL PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	111N00000X	Chiropractor
2	171100000X	Acupuncturist
3	2081S0010X	Sports Medicine (Physical Medicine & Rehabilitation) Physician
4	208100000X	Physical Medicine & Rehabilitation Physician

General Provider Information

NPI Number	:	1578099933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAXWELL 58 MEDICAL PC

Provider Business Mailing Address
First Line	:	111 BROADWAY
Second Line	:	SUITE 503
City	:	NEW YORK
State	:	NY
Zip	:	10006-1901
Country	:	US
Telephone Number	:	212-952-9355
Fax Number	:

Provider Business Practice Location Address
First Line	:	1441 BROADWAY
Second Line	:	SUITE 2403
City	:	NEW YORK
State	:	NY
Zip	:	10018-1905
Country	:	US
Telephone Number	:	212-404-8032
Fax Number	:

Authorized Official
Title or Position	:	INSURANCE DIRECTOR
Name	:	THANIA LOUISOR
Credential	:
Telephone Number	:	212-952-9355

Provider Enumeration Date	:	05/04/2017
Last Update Date	:	05/30/2024

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