Basic Information
| Provider Information | |||||||||
| NPI: | 1548310758 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRONXCARE HEALTH SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1276 FULTON AVE | ||||||||
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| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104563402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189018918 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1650 GRAND CONCOURSE | ||||||||
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| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189018600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 05/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | DEMARCO | ||||||||
| AuthorizedOfficialFirstName: | VICTOR | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7189018600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 01754636 | 05 | NY | MEDICAID |