=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013147800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOSEPH REALE PHYSICIAN ASSISTANT PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2009
-----------------------------------------------------
Last Update Date | 07/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12 ALFRED LN
-----------------------------------------------------
City | KINGS PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11754-5013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-532-7805
-----------------------------------------------------
Fax | 973-291-4439
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 ALFRED LN
-----------------------------------------------------
City | KINGS PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11754-5013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-532-7805
-----------------------------------------------------
Fax | 973-291-4439
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOSEPH REALE
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 516-532-7805
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 004677
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------