MEDICARE: DR. MARY ROSE QUAN LEE-LLACER M.D.

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	207R00000X	Internal Medicine Physician	180723	NY

General Provider Information

NPI Number	:	1750416970
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY ROSE QUAN LEE-LLACER M.D.

Provider Business Mailing Address
First Line	:	766 WOOLLEY AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-4248
Country	:	US
Telephone Number	:	718-698-0980
Fax Number	:

Provider Business Practice Location Address
First Line	:	766 WOOLLEY AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-4248
Country	:	US
Telephone Number	:	718-698-0980
Fax Number	:

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

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	07/08/2007

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