1982243887 NPI number — MEDALLIANCE MEDICAL HEALTH SERVICES

Table of content: (NPI 1982243887)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982243887 NPI number — MEDALLIANCE MEDICAL HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDALLIANCE MEDICAL HEALTH SERVICES
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:
1982243887
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 E FORDHAM RD
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:
10458-5049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-933-1900
Provider Business Mailing Address Fax Number:
718-563-4039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5041 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10034-1131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-869-2144
Provider Business Practice Location Address Fax Number:
646-869-4955
Provider Enumeration Date:
12/26/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BRAVO
Authorized Official First Name:
MARISOL
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMIN ASSISTANT/ CREDENTIALING
Authorized Official Telephone Number:
718-933-1900

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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