Basic Information
Provider Information | |||||||||
NPI: | 1053790147 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BRONXCARE HEALTH SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AMBULATORY CARE NETWORK | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1276 FULTON AVE FL 3 | ||||||||
Address2: |   | ||||||||
City: | BRONX | ||||||||
State: | NY | ||||||||
PostalCode: | 104563402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7189018600 | ||||||||
FaxNumber: | 7182931475 | ||||||||
Practice Location | |||||||||
Address1: | 1650 GRAND CONCOURSE | ||||||||
Address2: |   | ||||||||
City: | BRONX | ||||||||
State: | NY | ||||||||
PostalCode: | 10457 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7189018600 | ||||||||
FaxNumber: | 7182931457 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/22/2015 | ||||||||
LastUpdateDate: | 05/31/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DEMARCO | ||||||||
AuthorizedOfficialFirstName: | VICTOR | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VP-CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7189018600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BRONXCARE HEALTH SYSTEM | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 7000001H | NY | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 000163N | 01 | NY | BLUE CROSS | OTHER | 00476022 | 05 | NY |   | MEDICAID |