MEDICARE: CHARLOTTE BANILIVY

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	1721264231	NY

General Provider Information

NPI Number	:	1740960020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLOTTE BANILIVY

Provider Business Mailing Address
First Line	:	15 MAPLE GROVE ST
Second Line	:
City	:	GREAT NECK
State	:	NY
Zip	:	11023-1214
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	15 MAPLE GROVE ST
Second Line	:
City	:	GREAT NECK
State	:	NY
Zip	:	11023-1214
Country	:	US
Telephone Number	:	516-417-1341
Fax Number	:

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

Provider Enumeration Date	:	07/20/2023
Last Update Date	:	07/20/2023

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Directions to “ CHARLOTTE BANILIVY ” Practice Location

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