=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568771525
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DALTON MEDICAL SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2010
-----------------------------------------------------
Last Update Date | 09/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13620 38TH AVE SUITE 6F
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-4233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-888-9829
-----------------------------------------------------
Fax | 718-888-9796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 136-20 38 AVE SUITE 6F
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-888-9829
-----------------------------------------------------
Fax | 718-888-9796
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL LI
-----------------------------------------------------
Credential | MD PH.D
-----------------------------------------------------
Telephone | 718-888-9829
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 214851-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------