MEDICARE: KAREN WALSH RPT

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	0077400	NY

General Provider Information

NPI Number	:	1538334032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAREN WALSH RPT

Provider Business Mailing Address
First Line	:	2052 RICHMOND RD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-2583
Country	:	US
Telephone Number	:	718-816-6400
Fax Number	:	718-816-4677

Provider Business Practice Location Address
First Line	:	2052 RICHMOND RD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-2583
Country	:	US
Telephone Number	:	718-816-6500
Fax Number	:	718-816-4677

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

Provider Enumeration Date	:	04/25/2008
Last Update Date	:	01/25/2024

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