=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518746478
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMPIRE STATE MEDICAL WELLNESS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2023
-----------------------------------------------------
Last Update Date | 09/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8215 35TH AVE
-----------------------------------------------------
City | JACKSON HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11372-5233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-808-2615
-----------------------------------------------------
Fax | 347-808-2716
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8215 35TH AVE
-----------------------------------------------------
City | JACKSON HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11372-5233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-808-2615
-----------------------------------------------------
Fax | 347-808-2716
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ERVIN R RIANO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 908-644-4707
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------