1336114115 NPI number — MICHAEL DAVID HARGROVE M.D.

Table of content: MICHAEL DAVID HARGROVE M.D. (NPI 1336114115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336114115 NPI number — MICHAEL DAVID HARGROVE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARGROVE
Provider First Name:
MICHAEL
Provider Middle Name:
DAVID
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1336114115
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 MERLIN AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SLEEPY HOLLOW
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10591-1606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-490-8568
Provider Business Mailing Address Fax Number:
718-933-8208

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3130 GRAND CONCOURSE
Provider Second Line Business Practice Location Address:
SUITE B8
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-365-5662
Provider Business Practice Location Address Fax Number:
718-933-8208
Provider Enumeration Date:
02/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  188349 , 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: 01623812 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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