Basic Information
| Provider Information | |||||||||
| NPI: | 1851455885 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRONX LEBANON NEPHROLOGY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 260 | ||||||||
| Address2: | |||||||||
| City: | IRVINGTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105330260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185185232 | ||||||||
| FaxNumber: | 7185185636 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 SELWYN AVE | ||||||||
| Address2: | 8-G | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104577626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185185232 | ||||||||
| FaxNumber: | 7185185636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 05/07/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/28/2012 | ||||||||
| NPIReactivationDate: | 05/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | UDAY | ||||||||
| AuthorizedOfficialFirstName: | KALPANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER/PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7185185232 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 255628 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 03347266 | 05 | NY | MEDICAID | 1144391251 | 01 | NPI | OTHER | 00436677 | 05 | NY | MEDICAID | 01404737 | 05 | NY | MEDICAID | 1043263882 | 01 | NPI | OTHER | 02738810 | 05 | NY | MEDICAID | 1689833303 | 01 | NY | NPI | OTHER |