Basic Information
| Provider Information | |||||||||
| NPI: | 1154400406 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RECON-BUCEVIC | ||||||||
| FirstName: | MYRA | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7925 WINCHESTER BLVD | ||||||||
| Address2: | MANAGED CARE, D1-01 | ||||||||
| City: | QUEENS VILLAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114272128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182643950 | ||||||||
| FaxNumber: | 7182643591 | ||||||||
| Practice Location | |||||||||
| Address1: | 8268 164TH ST | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114321121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188833225 | ||||||||
| FaxNumber: | 7188836193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 03/28/2014 | ||||||||
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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 | 2084P0800X | 236892 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00246075 | 05 | NY | MEDICAID |