Basic Information
| Provider Information | |||||||||
| NPI: | 1740801018 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PERFORMANCE MEDICAL OFFICE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 LAKEVILLE RD STE 2 | ||||||||
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| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110401639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163885110 | ||||||||
| FaxNumber: | 5165179515 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 E 55TH ST FL 2 | ||||||||
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| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100223396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163885110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2020 | ||||||||
| LastUpdateDate: | 04/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | SCOTT | ||||||||
| AuthorizedOfficialFirstName: | MARVELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/MD | ||||||||
| AuthorizedOfficialTelephone: | 2122031835 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| NPICertificationDate: | 04/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.