MEDICARE: MMC GRAND CONCOURSE AT 3201

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	7000006H	NY

General Provider Information

NPI Number	:	1356535025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MMC GRAND CONCOURSE AT 3201

Provider Business Mailing Address
First Line	:	CMO
Second Line	:	100 CORPORATE DRIVE
City	:	YONKERS
State	:	NY
Zip	:	10701
Country	:	US
Telephone Number	:	914-377-4722
Fax Number	:

Provider Business Practice Location Address
First Line	:	MMC GRAND CONCOURSE AT 3201
Second Line	:	3201 GRAND CONCOURSE
City	:	BRONX
State	:	NY
Zip	:	10468-1247
Country	:	US
Telephone Number	:	914-377-4722
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MICHAEL G DOWLING
Credential	:
Telephone Number	:	914-377-4668

Provider Enumeration Date	:	09/05/2007
Last Update Date	:	09/05/2007

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