MEDICARE: WILLIAM VINCENT MARINO PA

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	363AM0700X	Medical Physician Assistant	000614	NY

General Provider Information

NPI Number	:	1558365387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM VINCENT MARINO PA

Provider Business Mailing Address
First Line	:	7 RUMSON RD
Second Line	:
City	:	KENDALL PARK
State	:	NJ
Zip	:	08824-1229
Country	:	US
Telephone Number	:	732-422-7963
Fax Number	:

Provider Business Practice Location Address
First Line	:	46 E BROADWAY
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10002-6803
Country	:	US
Telephone Number	:	212-343-3573
Fax Number	:

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

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	09/29/2008

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