Healthcare Provider Details

I. General information

NPI: 1174812812
Provider Name (Legal Business Name): EXCELLA MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4915 BROADWAY SUITE 1G
NEW YORK NY
10034-3119
US

IV. Provider business mailing address

4915 BROADWAY SUITE 1G
NEW YORK NY
10034-3119
US

V. Phone/Fax

Practice location:
  • Phone: 212-544-9513
  • Fax: 212-544-0402
Mailing address:
  • Phone: 212-544-9513
  • Fax: 212-544-0402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number170543
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number170543
License Number StateNY

VIII. Authorized Official

Name: MICHAEL PEREZ
Title or Position: MD
Credential:
Phone: 212-544-9513