Healthcare Provider Details

I. General information

NPI: 1588295141
Provider Name (Legal Business Name): MATTHEW MEKHAIL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2020
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

630 W 168TH ST # 4
NEW YORK NY
10032-3725
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-9564
  • Fax: 212-342-3591
Mailing address:
  • Phone: 212-305-9564
  • Fax: 212-342-3591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number309404
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number309404
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: