=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871252890
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVENUE MEDICAL WELLNESS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2021
-----------------------------------------------------
Last Update Date | 12/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 535 5TH AVE RM 603
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10017-8009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-200-5750
-----------------------------------------------------
Fax | 833-322-1167
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 535 5TH AVE RM 603
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10017-8009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-200-5757
-----------------------------------------------------
Fax | 833-322-1167
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LEAD PHYSICIAN
-----------------------------------------------------
Name | SHERA RAISEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 646-200-5750
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------