Provider Demographics
NPI:1417204736
Name:EXCELLA MEDICINE PC
Entity Type:Organization
Organization Name:EXCELLA MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-544-9513
Mailing Address - Street 1:4915 BROADWAY SUITE 1G
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-3122
Mailing Address - Country:US
Mailing Address - Phone:212-544-9513
Mailing Address - Fax:212-544-0402
Practice Address - Street 1:4915 BROADWAY SUITE 1G
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-3122
Practice Address - Country:US
Practice Address - Phone:212-544-9513
Practice Address - Fax:212-544-0402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170543207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF00310Medicare UPIN