=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770822736
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOTTENVILLE PRIMARY OSTEOPATHIC MEDICINE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2013
-----------------------------------------------------
Last Update Date | 06/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2955 VETERANS RD W
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10309-2515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-984-4094
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 70176
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10307-0176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-984-4094
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. THOMAS BOTTIGLIERI
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 718-984-4094
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 237430
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 237430
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------