MEDICARE: GAMMA 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	009550	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	009550	OTHER	NY	LICENSE

General Provider Information

NPI Number	:	1023369873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GAMMA CHIROPRACTIC PC

Provider Business Mailing Address
First Line	:	1332 FOREST AVE
Second Line	:	STATEN ISLAND
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-2043
Country	:	US
Telephone Number	:	718-442-8813
Fax Number	:	718-876-0158

Provider Business Practice Location Address
First Line	:	1332 FOREST AVE
Second Line	:	STATEN ISLAND
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-2043
Country	:	US
Telephone Number	:	718-442-8813
Fax Number	:	718-876-0158

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ALEXANDER MAZUROVSKY
Credential	:	DC
Telephone Number	:	718-998-3020

Provider Enumeration Date	:	09/19/2012
Last Update Date	:	09/19/2012

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