=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174871685
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRANDON MEDICAL WELLNESS OF NEW YORK PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2012
-----------------------------------------------------
Last Update Date | 08/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 274 MADISON AVE STE 705
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-0701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-481-0400
-----------------------------------------------------
Fax | 631-481-9631
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 274 MADISON AVE STE 705
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-0701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-481-0400
-----------------------------------------------------
Fax | 631-481-9631
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BRANDON ADEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 212-481-0400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 237639
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------