=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104876408
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAMDOUH M ELDEEB PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3250 WESTCHESTER AVE SUITE LL5
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10461-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-518-8040
-----------------------------------------------------
Fax | 718-518-8043
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18 FAITH LN
-----------------------------------------------------
City | ARDSLEY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10502-2529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-484-8210
-----------------------------------------------------
Fax | 718-518-8043
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 011463
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------