=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194278093
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANHATTAN ORTHOPEDIC & SPORTS MEDICINE GROUP, P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2016
-----------------------------------------------------
Last Update Date | 12/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2731 CRESCENT ST
-----------------------------------------------------
City | LONG ISLAND CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11102-4293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-204-0548
-----------------------------------------------------
Fax | 718-204-4928
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 57 W 57TH ST 15TH FLOOR
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10019-2802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-289-0700
-----------------------------------------------------
Fax | 212-289-0171
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | MICHELLE ROJAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-289-0700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------