MEDICARE: MR. EMMANUEL BENITEZ TSSLD

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	754352911	NY

General Provider Information

NPI Number	:	1851737696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EMMANUEL BENITEZ TSSLD

Provider Business Mailing Address
First Line	:	897 TIFFANY ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10459-4307
Country	:	US
Telephone Number	:	646-842-0435
Fax Number	:

Provider Business Practice Location Address
First Line	:	897 TIFFANY ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10459-4307
Country	:	US
Telephone Number	:	646-842-0435
Fax Number	:

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

Provider Enumeration Date	:	05/20/2013
Last Update Date	:	05/20/2013

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