=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578991055
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGER & GOUGELMAN, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2013
-----------------------------------------------------
Last Update Date | 10/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 ORCHARD ST SUITE 305
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06511-5363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-773-1753
-----------------------------------------------------
Fax | 203-773-9895
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 345 E 37TH ST SUITE #316
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-3256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-661-3939
-----------------------------------------------------
Fax | 212-661-0576
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MRS. SANDRA DIAZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-661-3939
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------