=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346482429
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA CATHERINE CARMODY-BAVASI PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2009
-----------------------------------------------------
Last Update Date | 10/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1275 YORK AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10065-6007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-639-2024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 512 E 80TH ST #24
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10075-0755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-249-1349
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207YX0905X
-----------------------------------------------------
Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
-----------------------------------------------------
License Number | 010700
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 010700
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------