Basic Information
| Provider Information | |||||||||
| NPI: | 1629313945 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRONXCARE HEALTH SYSTEM | ||||||||
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| OtherOrganizationName: | GI | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1276 FULTON AVE | ||||||||
| Address2: | ROOM 208 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104563402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189018918 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1650 GRAND CONCOURSE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189018918 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2012 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | DEMARCO | ||||||||
| AuthorizedOfficialFirstName: | VICTOR | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVR/CFO | ||||||||
| AuthorizedOfficialTelephone: | 7189018600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BRONXCARE HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.