Healthcare Provider Details

I. General information

NPI: 1568699585
Provider Name (Legal Business Name): DYSAUTONOMIA CENTER LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 06/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 1ST AVE SUITE 9Q
NEW YORK NY
10016-6402
US

IV. Provider business mailing address

530 1ST AVE SUITE 9Q
NEW YORK NY
10016-6402
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-7225
  • Fax: 212-263-7041
Mailing address:
  • Phone: 212-263-7225
  • Fax: 212-263-7041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number168166
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number099123
License Number StateNY

VIII. Authorized Official

Name: DR. FELICIA AXELROD
Title or Position: PARTNER
Credential:
Phone: 212-263-7225