=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427889609
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAMED EID PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2024
-----------------------------------------------------
Last Update Date | 08/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 RALPH PL STE 217
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10304-4416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-724-1509
-----------------------------------------------------
Fax | 914-407-1996
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 MOSELY AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10312-4165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 052588
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------