1205963972 NPI number — MONTEFIORE MEDICAL CENTER-MONTEFIORE PHARMACY

Table of content: DR. MICHAEL ROBERT BLACK DPM (NPI 1851589055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205963972 NPI number — MONTEFIORE MEDICAL CENTER-MONTEFIORE PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONTEFIORE MEDICAL CENTER-MONTEFIORE PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205963972
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 E 210TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10467-2401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-920-5194
Provider Business Mailing Address Fax Number:
718-652-0733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3444 KOSSUTH AVE
Provider Second Line Business Practice Location Address:
GROUND FLOOR
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10467-2410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-920-4300
Provider Business Practice Location Address Fax Number:
718-652-0733
Provider Enumeration Date:
02/28/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TUCKMAN
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
718-920-4300

Provider Taxonomy Codes

  • Taxonomy code: 3336I0012X , with the licence number:  000475 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0002X , with the licence number: 000475 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 000475 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 032128 . This is a "PHARMACY LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".