MEDICARE: JERRY ELLSTEIN M.D.

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	207XS0106X	Orthopaedic Hand Surgery Physician	136138	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	136138	OTHER	NY	LICENSE

General Provider Information

NPI Number	:	1366480675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY ELLSTEIN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 92
Second Line	:
City	:	GLEN HEAD
State	:	NY
Zip	:	11545-0092
Country	:	US
Telephone Number	:	631-427-4263
Fax Number	:	631-427-4279

Provider Business Practice Location Address
First Line	:	166 E MAIN ST
Second Line	:
City	:	HUNTINGTON
State	:	NY
Zip	:	11743-2948
Country	:	US
Telephone Number	:	631-427-4263
Fax Number	:	631-427-4279

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	02/21/2012

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