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General NPI Number Information
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NPI Number | 1659628832
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Entity Type | Organization
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Legal Business Name | LEGACY MEDICAL PLLC
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Dates
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Enumeration Date | 08/07/2012
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Last Update Date | 08/07/2012
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Provider Practice Location Address
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Address Line | 19 W 34TH ST SUITE1200
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City | NEW YORK
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State | NY
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Zip | 10001-3006
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Country | US
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Telephone | 212-924-7676
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Fax | 212-924-7676
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Provider Business Mailing Address
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Address Line | 19 WEST 34TH STREET SUITE1200
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City | NEW YORK
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State | NY
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Zip | 10001-3006
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Country | US
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Telephone | 212-924-7676
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Fax | 212-531-6136
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Authorized Official
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Title or Position | OWNER
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Name | MADHU BOPPANA
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Credential | M.D.
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Telephone | 212-924-7676
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 199052-1
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License Number State | NY
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