=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609284504
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAY M PURVIN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2014
-----------------------------------------------------
Last Update Date | 07/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 467 MERRICK AVE
-----------------------------------------------------
City | EAST MEADOW
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11554-2719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-489-1950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 467 MERRICK AVE
-----------------------------------------------------
City | EAST MEADOW
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11554-2719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-489-1950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DPM
-----------------------------------------------------
Name | DR. JAY M PURVIN
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 516-489-1950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | N002971-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------