=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730524455
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FM MCLAUGHLIN MEDICAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2013
-----------------------------------------------------
Last Update Date | 09/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2901 3RD AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10455-2638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-993-5093
-----------------------------------------------------
Fax | 718-993-5099
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2901 3RD AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10455-2638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-993-5093
-----------------------------------------------------
Fax | 718-993-5099
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. FERNANDO SEBASTIAN MORA-MCLAUGHLIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 718-993-5093
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 212244
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------