=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083926976
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEVIN H WEINER, MD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2010
-----------------------------------------------------
Last Update Date | 07/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2071 CLOVE RD
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10304-1671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-442-4422
-----------------------------------------------------
Fax | 718-556-3025
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2071 CLOVE RD
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10304-1671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-442-4422
-----------------------------------------------------
Fax | 718-556-3025
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | KEVIN H WEINER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 718-442-4422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 202165
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------