Healthcare Provider Details

I. General information

NPI: 1104427442
Provider Name (Legal Business Name): MEDICAL AND WELLNESS PRACTICE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 TOMPKINS AVE
STATEN ISLAND NY
10305-1745
US

IV. Provider business mailing address

PO BOX 103
HILLSDALE NJ
07642-0103
US

V. Phone/Fax

Practice location:
  • Phone: 877-241-2772
  • Fax:
Mailing address:
  • Phone: 201-522-3205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN SOU-CHENG SHIAU
Title or Position: PRESIDENT
Credential: MD
Phone: 917-886-5276