=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538441902
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TODT HILL ENDOSCOPY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2011
-----------------------------------------------------
Last Update Date | 12/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 78 TODT HILL RD SUITE 203
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10314-4513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-448-1122
-----------------------------------------------------
Fax | 718-448-8318
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 78 TODT HILL RD SUITE 203
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10314-4513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-448-1122
-----------------------------------------------------
Fax | 718-448-8318
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WALLEN CHAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 718-448-1122
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 094864
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------