=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508413097
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROGRESSIVE MEDICAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2019
-----------------------------------------------------
Last Update Date | 12/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 JERSEY ST
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10301-2976
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-524-5611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 460 N MAPLE AVE
-----------------------------------------------------
City | EAST ORANGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07017-4674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ELLIS ENABOSI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 973-280-9600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------