MEDICARE: SOLSTICE MEDICAL GROUP PLLC

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	208D00000X	General Practice Physician	150519	NY

General Provider Information

NPI Number	:	1841516101
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOLSTICE MEDICAL GROUP PLLC

Provider Business Mailing Address
First Line	:	230 BEACH 102ND ST
Second Line	:	SUITE # 4 B
City	:	ROCKAWAY PARK
State	:	NY
Zip	:	11694-2871
Country	:	US
Telephone Number	:	718-474-4734
Fax Number	:	718-474-4738

Provider Business Practice Location Address
First Line	:	230 BEACH 102ND ST
Second Line	:	SUITE # 4 B
City	:	ROCKAWAY PARK
State	:	NY
Zip	:	11694-2871
Country	:	US
Telephone Number	:	718-474-4734
Fax Number	:	718-474-4738

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MILIVOJEI MILOSEVIC
Credential	:	MD
Telephone Number	:	718-474-4734

Provider Enumeration Date	:	04/12/2010
Last Update Date	:	04/12/2010

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