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General NPI Number Information
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NPI Number | 1750541199
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Entity Type | Organization
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Legal Business Name | POLYXENA MEDICAL CORPORATION PC
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Dates
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Enumeration Date | 06/10/2008
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Last Update Date | 06/10/2008
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Provider Practice Location Address
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Address Line | 1556 3RD AVE
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City | NEW YORK
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State | NY
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Zip | 10128-3100
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Country | US
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Telephone | 212-410-2539
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Fax |
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Provider Business Mailing Address
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Address Line | 1556 3RD AVE
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City | NEW YORK
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State | NY
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Zip | 10128-3100
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Country | US
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Telephone | 212-410-2539
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TATIANA MAMAEVA
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Credential | M.D.
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Telephone | 212-410-2539
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number |
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License Number State |
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