MEDICARE: PRIDE MEDICAL, PLLC

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	261QP2300X	Primary Care Clinic/Center		NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1083700926	OTHER	NY	NPI

General Provider Information

NPI Number	:	1922214600
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIDE MEDICAL, PLLC

Provider Business Mailing Address
First Line	:	3875 BROADWAY
Second Line	:	UNIT B
City	:	NEW YORK
State	:	NY
Zip	:	10032-1567
Country	:	US
Telephone Number	:	917-656-2951
Fax Number	:

Provider Business Practice Location Address
First Line	:	3875 BROADWAY
Second Line	:	UNIT B
City	:	NEW YORK
State	:	NY
Zip	:	10032-1567
Country	:	US
Telephone Number	:	917-656-2951
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PUNYADECH PHOTANGTHAM
Credential	:	MD
Telephone Number	:	917-656-2951

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	11/23/2015

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