=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245692185
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARY MANNING WALSH HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2016
-----------------------------------------------------
Last Update Date | 03/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1339 YORK AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10021-4707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-628-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 1ST AVE APT 11E
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10009-2614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-669-8313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | ELLIOT SCHWARTZ
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 212-628-2800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | F305903-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------