Basic Information
| Provider Information | |||||||||
| NPI: | 1760677041 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MMC AT WALTON HIGH SCHOOL | ||||||||
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| Mailing Information | |||||||||
| Address1: | CMO | ||||||||
| Address2: | 100 CORPORATE DRIVE | ||||||||
| City: | YONKERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9143774722 | ||||||||
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| Practice Location | |||||||||
| Address1: | MMC AT WALTON HIGH SCHOOL | ||||||||
| Address2: | 2780 RESERVOIR AVENUE | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104682702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9143774722 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2007 | ||||||||
| LastUpdateDate: | 09/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | DOWLING | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9143774668 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MONTEFIORE MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | 7000006H | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.