=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437196136
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLEN D. WAITZKIN MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2006
-----------------------------------------------------
Last Update Date | 01/22/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 525 E 68TH ST 8A37
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10065-4870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-646-2520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 587 HANOVER CENTER ROAD
-----------------------------------------------------
City | HANOVER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-643-3102
-----------------------------------------------------
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 | 60 250982
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 57349
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 12207
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------