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NPI Code Detail

MEDICARE: SOUTHERN WELLCARE MEDICAL PC

MEDICARE: SOUTHERN WELLCARE MEDICAL PC
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
1207Q00000XFamily Medicine Physician228243NY

General Provider Information

NPI Number : 1396090932
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTHERN WELLCARE MEDICAL PC
Provider Business Mailing Address
First Line : 2336 GRAND CONCOURSE
Second Line :
City : BRONX
State : NY
Zip : 10458-6903
Country : US
Telephone Number : 718-220-0439
Fax Number : 718-933-2914
Provider Business Practice Location Address
First Line : 2336 GRAND CONCOURSE
Second Line :
City : BRONX
State : NY
Zip : 10458-6903
Country : US
Telephone Number : 718-907-0195
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : SVETLANA KHANDROS
Credential : D.O.
Telephone Number : 718-220-0439
Provider Enumeration Date : 07/19/2012
Last Update Date : 10/17/2019

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Directions to “SOUTHERN WELLCARE MEDICAL PC ” Practice Location

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