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General NPI Number Information
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NPI Number | 1740315225
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Entity Type | Organization
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Legal Business Name | EAST 29TH ST MEDICAL ASSOCIATES, P.C.
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Dates
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Enumeration Date | 02/23/2007
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Last Update Date | 03/24/2011
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Provider Practice Location Address
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Address Line | 542 E 29TH STREET
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City | PATERSON
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State | NJ
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Zip | 07504-1814
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Country | US
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Telephone | 201-281-8691
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Fax |
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Provider Business Mailing Address
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Address Line | 716 HUNTINGTON CHASE CT
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City | WARNER ROBINS
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State | GA
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Zip | 31088-2681
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Country | US
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Telephone | 201-281-8692
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SHELLY D SAMUEL
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Credential | MD
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Telephone | 201-281-8692
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | MA71838
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License Number State | NJ
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