MEDICARE: MR. EDGARDO MESIAS LIVICA RPT

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	261QP2000X	Physical Therapy Clinic/Center	015653	NY
2	225100000X	Physical Therapist	015653	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0129225	OTHER	NY	GHI
3	2558827	OTHER	NY	UNITED HEALTHCARE

General Provider Information

NPI Number	:	1669468666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EDGARDO MESIAS LIVICA RPT

Provider Business Mailing Address
First Line	:	1577 LURTING AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10461-1509
Country	:	US
Telephone Number	:	718-822-8490
Fax Number	:

Provider Business Practice Location Address
First Line	:	787 LYDIG AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10462-2144
Country	:	US
Telephone Number	:	718-775-6025
Fax Number	:

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

Provider Enumeration Date	:	09/25/2005
Last Update Date	:	05/24/2021

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