=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467962977
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH CARRIAGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2017
-----------------------------------------------------
Last Update Date | 10/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 512 BEACH DR
-----------------------------------------------------
City | MEDINA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14103-1004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-331-6752
-----------------------------------------------------
Fax | 585-331-6752
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 70243
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10307-0243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-331-6752
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | JOHN MORIARTY
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 585-331-6752
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 006888
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------