Basic Information
Provider Information | |||||||||
NPI: | 1093900326 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MMC MEDICAL PARK AT 1635 POPLAR | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 CORPORATE DRIVE | ||||||||
Address2: | CMO | ||||||||
City: | YONKERS | ||||||||
State: | NY | ||||||||
PostalCode: | 10701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9143774722 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1635 POPLAR STREETMMC | ||||||||
Address2: | MMC MEDICAL PARK AT 1635 POPLAR | ||||||||
City: | BRONX | ||||||||
State: | NY | ||||||||
PostalCode: | 104612659 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9143774722 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/10/2007 | ||||||||
LastUpdateDate: | 09/10/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DOWLING | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9143774668 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MONTEFIORE MEDICAL CENTER | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | 7000006H | NY | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.