=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235762899
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 121 MEDICAL P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2020
-----------------------------------------------------
Last Update Date | 05/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5030 BROADWAY STE 818
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10034-1670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-316-0487
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5030 BROADWAY STE 818
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10034-1670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-316-0487
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JANIL CRUZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-567-4931
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------