MEDICARE: SRN CHIROPRACTIC, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	X006877-1	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	07869	OTHER	NY	GHI MEDICARE

General Provider Information

NPI Number	:	1013003912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SRN CHIROPRACTIC, PC

Provider Business Mailing Address
First Line	:	174 GRAND ST
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10601-4803
Country	:	US
Telephone Number	:	914-328-8077
Fax Number	:	914-328-6083

Provider Business Practice Location Address
First Line	:	6517 MYRTLE AVE
Second Line	:
City	:	GLENDALE
State	:	NY
Zip	:	11385-6248
Country	:	US
Telephone Number	:	718-497-1150
Fax Number	:	718-417-0912

Authorized Official
Title or Position	:	PROVIDER COORDINATOR
Name	:	CORNELIA KRIEGER
Credential	:
Telephone Number	:	914-328-8077

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	04/23/2008

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