MEDICARE: DIVINE MEDICAL LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952920795
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE MEDICAL LLC

Provider Business Mailing Address
First Line	:	13163 233RD ST # 1
Second Line	:
City	:	ROSEDALE
State	:	NY
Zip	:	11422-1305
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13163 233RD ST # 1
Second Line	:
City	:	ROSEDALE
State	:	NY
Zip	:	11422-1305
Country	:	US
Telephone Number	:	718-525-3347
Fax Number	:

Authorized Official
Title or Position	:	CEO/MEDICAL DIRECTOR
Name	:	DR. AUGUSTINE UMEOZOR
Credential	:
Telephone Number	:	917-742-2442

Provider Enumeration Date	:	04/12/2020
Last Update Date	:	04/12/2020

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Directions to “DIVINE MEDICAL LLC ” Practice Location

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