MEDICARE: IMELDA CRUZ-BANTING, MD, 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	261QM2500X	Medical Specialty Clinic/Center	212537	NY
2	261Q00000X	Clinic/Center	212537	NY

General Provider Information

NPI Number	:	1467642140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMELDA CRUZ-BANTING, MD, PC

Provider Business Mailing Address
First Line	:	12 APPLE CT
Second Line	:
City	:	EASTCHESTER
State	:	NY
Zip	:	10709-5540
Country	:	US
Telephone Number	:	914-779-3710
Fax Number	:	718-944-6266

Provider Business Practice Location Address
First Line	:	108 VAN GUILDER AVE
Second Line	:
City	:	NEW ROCHELLE
State	:	NY
Zip	:	10801-5406
Country	:	US
Telephone Number	:	914-712-3144
Fax Number	:	718-944-6266

Authorized Official
Title or Position	:	OWNER
Name	:	DR. IMELDA MANGAHAS CRUZ-BANTING
Credential	:
Telephone Number	:	914-779-3710

Provider Enumeration Date	:	07/27/2007
Last Update Date	:	07/27/2007

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