MEDICARE: MARIO FUNICELLI

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	111NN0400X	Neurology Chiropractor	X007427-1	NY

General Provider Information

NPI Number	:	1790810232
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIO FUNICELLI

Provider Business Mailing Address
First Line	:	1931 RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3889
Country	:	US
Telephone Number	:	718-477-9300
Fax Number	:	718-477-9301

Provider Business Practice Location Address
First Line	:	1931 RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3889
Country	:	US
Telephone Number	:	718-477-9300
Fax Number	:	718-477-9301

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

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	08/29/2014

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Directions to “ MARIO FUNICELLI ” Practice Location

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