=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831451244
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POMONA OB GYN PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2012
-----------------------------------------------------
Last Update Date | 06/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26 FIREMENS MEMORIAL DR SUITE 120B
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10970-3553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-362-5900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26 FIREMENS MEMORIAL DR SUITE 120B
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10970-3553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-362-5900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JUDITH STAVIS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 845-362-5900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------