MEDICARE: DR. JAY MITCHELL KORNGOLD 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	174400000X	Specialist	222599-1	NY
2	174400000X	Specialist	25MA07711400	NJ

General Provider Information

NPI Number	:	1386795664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAY MITCHELL KORNGOLD M.D.

Provider Business Mailing Address
First Line	:	125 S MAIN ST
Second Line	:
City	:	NEW CITY
State	:	NY
Zip	:	10956-3501
Country	:	US
Telephone Number	:	845-634-4554
Fax Number	:	845-639-1959

Provider Business Practice Location Address
First Line	:	125 S MAIN ST
Second Line	:
City	:	NEW CITY
State	:	NY
Zip	:	10956-3501
Country	:	US
Telephone Number	:	845-634-4554
Fax Number	:	845-639-1959

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

Provider Enumeration Date	:	01/15/2007
Last Update Date	:	07/08/2007

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