NPI |
1043738586 |
|
Entity Type Code |
2 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
Employer Identification Number EIN |
|
The middle name of the provider, if the provider
is an individual. |
Provider Organization Name Legal Business Name |
DIABETES RELIEF CENTER OF BRONX MSO LLC |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
Provider First Line Business Practice Location Address |
2825 3RD AVE STE 200 |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
Provider Business Practice Location Address City Name |
BRONX |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address State Name |
NY |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address Postal Code |
104554066 |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
9165501050 |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Fax Number |
9165501238 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Provider Enumeration Date |
9/5/2017 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Last Update Date |
9/5/2017 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Authorized Official Last Name |
WALLACE |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
Authorized Official First Name |
DEANE' |
The first name of the authorized official. |
Authorized Official Title or Position |
CREDENTIALING SPECIALIST |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
Authorized Official Telephone Number |
9165719041 |
The 10-position telephone number of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
207R00000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Is Organization Subpart |
N |
|
Healthcare Provider Taxonomy Group 1 |
193200000X MULTI-SPECIALTY GROUP |
|