MEDICARE: MEDALLIANCE MEDICAL HEALTH SERVICES

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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1982243887
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDALLIANCE MEDICAL HEALTH SERVICES

Provider Business Mailing Address
First Line	:	625 E FORDHAM RD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10458-5049
Country	:	US
Telephone Number	:	718-933-1900
Fax Number	:	718-563-4039

Provider Business Practice Location Address
First Line	:	5041 BROADWAY
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10034-1131
Country	:	US
Telephone Number	:	646-869-2144
Fax Number	:	646-869-4955

Authorized Official
Title or Position	:	ADMIN ASSISTANT/ CREDENTIALING
Name	:	MARISOL BRAVO
Credential	:
Telephone Number	:	718-933-1900

Provider Enumeration Date	:	12/26/2019
Last Update Date	:	12/26/2019

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