MEDICARE: CROWN NEUROLOGY, P.C.

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	207R00000X	Internal Medicine Physician	266135-1	NY
2	2084N0400X	Neurology Physician	266135-1	NY
3	2084V0102X	Vascular Neurology Physician	266135-1	NY

General Provider Information

NPI Number	:	1114380383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROWN NEUROLOGY, P.C.

Provider Business Mailing Address
First Line	:	405 19TH ST S
Second Line	:
City	:	BRIGANTINE
State	:	NJ
Zip	:	08203-2027
Country	:	US
Telephone Number	:	917-902-8169
Fax Number	:

Provider Business Practice Location Address
First Line	:	1181 WOODROW RD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10309-1723
Country	:	US
Telephone Number	:	917-902-8169
Fax Number	:

Authorized Official
Title or Position	:	M.D./OWNER
Name	:	DR. JONATHAN GLENN GUTERMAN
Credential	:	M.D.
Telephone Number	:	917-902-8169

Provider Enumeration Date	:	04/04/2016
Last Update Date	:	04/04/2016

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