Basic Information
| Provider Information | |||||||||
| NPI: | 1619275039 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRONXCARE DR. MARTIN LUTHER KING JR. HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRONXCARE DENTAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1276 FULTON AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104563402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189018600 | ||||||||
| FaxNumber: | 7182931475 | ||||||||
| Practice Location | |||||||||
| Address1: | 1775 GRAND CONCOURSE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189018600 | ||||||||
| FaxNumber: | 7182931475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2011 | ||||||||
| LastUpdateDate: | 06/28/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEMARCO | ||||||||
| AuthorizedOfficialFirstName: | VICTOR | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP-CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7189018600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BRONXCARE DR. MARTIN LUTHER KING JR HEALTH CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 7000212R | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 03410919 | 05 | NY | MEDICAID | W0437 | 01 | NY | BLUE CROSS | OTHER |