MEDICARE: MRS. MARY THERESA GIAMMANCO

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	980594	NY

General Provider Information

NPI Number	:	1568890267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY THERESA GIAMMANCO

Provider Business Mailing Address
First Line	:	87 CAMPBELL LN
Second Line	:
City	:	EAST ISLIP
State	:	NY
Zip	:	11730-3617
Country	:	US
Telephone Number	:	631-835-6936
Fax Number	:

Provider Business Practice Location Address
First Line	:	87 CAMPBELL LN
Second Line	:
City	:	EAST ISLIP
State	:	NY
Zip	:	11730-3617
Country	:	US
Telephone Number	:	631-835-6936
Fax Number	:

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

Provider Enumeration Date	:	10/16/2013
Last Update Date	:	10/16/2013

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