Basic Information
| Provider Information | |||||||||
| NPI: | 1740371392 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOLINE | ||||||||
| FirstName: | CLELIA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 E 233RD ST | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104662604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189209647 | ||||||||
| FaxNumber: | 7189206812 | ||||||||
| Practice Location | |||||||||
| Address1: | 4170 BRONX BLVD | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104662656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189209600 | ||||||||
| FaxNumber: | 7189206840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 197531 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1663556 | 05 | NY | MEDICAID |