1710156211 NPI number — BETHEL MEDICAL PRACTICE P.C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710156211 NPI number — BETHEL MEDICAL PRACTICE P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BETHEL MEDICAL PRACTICE P.C
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:
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:
1710156211
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2160 ANTHONY AVE
Provider Second Line Business Mailing Address:
APT # 4F
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-463-7552
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2869 GRAND CONCORSE
Provider Second Line Business Practice Location Address:
SUITE # 1
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10468
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-676-4177
Provider Business Practice Location Address Fax Number:
718-676-4179
Provider Enumeration Date:
02/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SANTANA
Authorized Official First Name:
DOMINGO
Authorized Official Middle Name:
ANTHONIO
Authorized Official Title or Position:
M.D
Authorized Official Telephone Number:
718-676-4177

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  239271 , 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)





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