=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699239251
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GYNECOLOGY AND INTEGRATIVE WOMEN'S CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2019
-----------------------------------------------------
Last Update Date | 01/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 E 23RD ST FL 7
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10010-4440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-606-9678
-----------------------------------------------------
Fax | 212-202-6005
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 E 25TH ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10010-2914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-606-9678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. STEPHANIE MCCLELLAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 949-933-6827
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------