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General NPI Number Information
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NPI Number | 1083194351
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Entity Type | Organization
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Legal Business Name | MANHATTAN INTEGRATIVE GASTROENTEROLOGY
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Dates
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Enumeration Date | 08/16/2018
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Last Update Date | 08/17/2018
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Provider Practice Location Address
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Address Line | 550 VANDERBILT AVE APT 803
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City | BROOKLYN
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State | NY
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Zip | 11238
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Country | US
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Telephone | 917-825-9237
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Fax |
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Provider Business Mailing Address
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Address Line | 928 BROADWAY STE 400
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City | NEW YORK
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State | NY
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Zip | 10010-8149
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Country | US
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Telephone | 212-634-4233
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. ALEXANDRA SHUSTINA
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Credential | DO
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Telephone | 212-634-4233
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 255074
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License Number State | NY
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