MEDICARE: CAROLIN T PENROSE 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	207N00000X	Dermatology Physician	245597	NY

General Provider Information

NPI Number	:	1790946655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLIN T PENROSE M.D.

Provider Business Mailing Address
First Line	:	1110 SOUTH AVE
Second Line	:	SUITE 400
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3411
Country	:	US
Telephone Number	:	917-830-1415
Fax Number	:	917-830-1418

Provider Business Practice Location Address
First Line	:	1110 SOUTH AVE
Second Line	:	SUITE 400
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3411
Country	:	US
Telephone Number	:	917-830-1415
Fax Number	:	917-830-1418

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

Provider Enumeration Date	:	06/23/2008
Last Update Date	:	06/10/2016

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