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1309 Fulton Avenue Nycdohmh Mott Haven Connect Cmcm Bronx NY 10456-2403 | |
| (718) 367-2450 | |
| (718) 367-5112 |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Community Health |
| Location | 1309 Fulton Avenue, Bronx, New York |
| Authorized Official Name and Position | Michael James Smook (ADMINISTRATIVE MGR 3D PARTY REVENUE) |
| Authorized Official Contact | 2124425468 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
125 Worth Street Nycdohmh Div Of Disease Control Rm 901 Box 22 New York NY 10004-4006 Ph: (212) 442-8468 | 1309 Fulton Avenue Nycdohmh Mott Haven Connect Cmcm Bronx NY 10456-2403 Ph: (718) 367-2450 |
| NPI Number | 1104872506 |
|---|---|
| Provider Enumeration Date | 05/26/2006 |
| Last Update Date | 08/22/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1104872506 | NPI | - | NPPES |
| 01234413 | Medicaid | NY |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QC1500X | Clinic/center - Community Health | 01234413026 (New York) | Primary |
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