=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205004181
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMB MEDICAL, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2008
-----------------------------------------------------
Last Update Date | 03/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9522 63RD RD 531
-----------------------------------------------------
City | REGO PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11374-1142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-271-3548
-----------------------------------------------------
Fax | 718-606-0719
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9522 63RD RD #531
-----------------------------------------------------
City | REGO PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11374-1142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-271-3548
-----------------------------------------------------
Fax | 718-606-0719
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STEPHANIE BAYNER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 718-271-3548
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 231488
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------