Basic Information
| Provider Information | |||||||||
| NPI: | 1275582181 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST COAST WOUND CARE P C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 976 MCLEAN AVE | ||||||||
| Address2: | SUITE 387 | ||||||||
| City: | YONKERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 107044105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142376797 | ||||||||
| FaxNumber: | 9142376790 | ||||||||
| Practice Location | |||||||||
| Address1: | 976 MCLEAN AVE | ||||||||
| Address2: | SUITE 387 | ||||||||
| City: | YONKERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 107044105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142376797 | ||||||||
| FaxNumber: | 9142376790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 07/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | BUNKER | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9142376797 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0360569772 | 01 | IL | MEDICAID | OTHER | 277265500 | 05 | FL | MEDICAID | 200216370A | 05 | OK | MEDICAID | 0050431 | 01 | NJ | MEDICAID | OTHER |