=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356401855
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANANDA & POULOSE MEDICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 190 WILLIS AVE SUITE 210
-----------------------------------------------------
City | MINEOLA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11501-2649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-739-7290
-----------------------------------------------------
Fax | 516-739-7291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 190 WILLIS AVE SUITE 210
-----------------------------------------------------
City | MINEOLA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11501-2649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-739-7290
-----------------------------------------------------
Fax | 516-739-7291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | ANUPAMA ANANDA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 516-739-7290
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------