MEDICARE: LASER EYE PRACTICE OF NEW YORK, PLLC

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	091370	NY

General Provider Information

NPI Number	:	1578752705
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LASER EYE PRACTICE OF NEW YORK, PLLC

Provider Business Mailing Address
First Line	:	1 N WASHINGTON AVE
Second Line	:
City	:	BERGENFIELD
State	:	NJ
Zip	:	07621-2125
Country	:	US
Telephone Number	:	201-384-7333
Fax Number	:	201-385-3881

Provider Business Practice Location Address
First Line	:	1755 YORK AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10128-6849
Country	:	US
Telephone Number	:	212-722-7629
Fax Number	:	212-722-4860

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. JOSEPH DELLO RUSSO
Credential	:	M.D
Telephone Number	:	212-722-7629

Provider Enumeration Date	:	10/24/2007
Last Update Date	:	06/19/2008

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