=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538486907
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | UNKNOWN MUNISH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2010
-----------------------------------------------------
Last Update Date | 09/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 134 HOMER AVE
-----------------------------------------------------
City | CORTLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13045-1206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-834-9200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 509 BRIAR BROOK RUN
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13066-8751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-352-9287
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 316194
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 5680 J&K MRC
-----------------------------------------------------
License Number State | ZZ
-----------------------------------------------------