MEDICARE: DR. JISHA EDICHANDY D.O.

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	208000000X	Pediatrics Physician	48653	CT

General Provider Information

NPI Number	:	1508161738
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JISHA EDICHANDY D.O.

Provider Business Mailing Address
First Line	:	7632 264TH ST
Second Line	:
City	:	FLORAL PARK
State	:	NY
Zip	:	11004-1145
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7632 264TH ST
Second Line	:
City	:	FLORAL PARK
State	:	NY
Zip	:	11004-1145
Country	:	US
Telephone Number	:	917-647-7822
Fax Number	:

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

Provider Enumeration Date	:	01/19/2011
Last Update Date	:	01/19/2011

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