=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841210689
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITE MEDICAL, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2006
-----------------------------------------------------
Last Update Date | 03/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11905 80TH RD
-----------------------------------------------------
City | KEW GARDENS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11415-1105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-635-1210
-----------------------------------------------------
Fax | 718-663-7134
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11905 80TH RD
-----------------------------------------------------
City | KEW GARDENS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11415-1105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-635-1210
-----------------------------------------------------
Fax | 718-663-7134
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT EDMUND WHITE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 718-635-1210
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 163661
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------