=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356692859
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOWER EAST SIDE FAMILY MEDICINE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2012
-----------------------------------------------------
Last Update Date | 01/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 260 E BROADWAY STE 2
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10002-5609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-777-4329
-----------------------------------------------------
Fax | 212-777-4301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 260 E BROADWAY STE 2
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10002-5609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-777-4329
-----------------------------------------------------
Fax | 212-777-4301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER/OWNER
-----------------------------------------------------
Name | DR. TERESA CHAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 212-777-4329
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 213958
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------