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General NPI Number Information
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NPI Number | 1417204736
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Entity Type | Organization
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Legal Business Name | EXCELLA MEDICINE PC
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Dates
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Enumeration Date | 08/06/2012
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Last Update Date | 08/06/2012
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Provider Practice Location Address
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Address Line | 4915 BROADWAY SUITE 1G
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City | NEW YORK
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State | NY
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Zip | 10034-3122
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Country | US
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Telephone | 212-544-9513
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Fax | 212-544-0402
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Provider Business Mailing Address
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Address Line | 4915 BROADWAY SUITE 1G
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City | NEW YORK
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State | NY
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Zip | 10034-3122
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Country | US
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Telephone | 212-544-9513
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Fax | 212-544-0402
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Authorized Official
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Title or Position | MEDICAL DOCTOR
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Name | MICHAEL PEREZ
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Credential | M.D
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Telephone | 212-544-9513
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 170543
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License Number State | NY
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