=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689859480
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NY INTEGRATIVE MEDICINE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2007
-----------------------------------------------------
Last Update Date | 12/31/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4809 8TH AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11220-2213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-925-8839
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4809 8TH AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11220-2213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-925-8839
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LUGUANG YANG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 212-925-8839
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225400000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Practitioner
-----------------------------------------------------
License Number | 204326
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------