MEDICARE: MR. JUSTIN IAN SHMUEL B.A

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	246ZE0600X	Electroneurodiagnostic Specialist/Technologist

General Provider Information

NPI Number	:	1568092005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUSTIN IAN SHMUEL B.A

Provider Business Mailing Address
First Line	:	7625 270TH ST
Second Line	:
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11040-1417
Country	:	US
Telephone Number	:	917-470-5351
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 KNOLLWOOD RD
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10607-1217
Country	:	US
Telephone Number	:	888-787-6267
Fax Number	:

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

Provider Enumeration Date	:	01/23/2020
Last Update Date	:	01/23/2020

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