Healthcare Provider Details

I. General information

NPI: 1619973518
Provider Name (Legal Business Name): PERRY AVE FAMILY MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3071 PERRY AVE
BRONX NY
10467-4111
US

IV. Provider business mailing address

3071 PERRY AVE
BRONX NY
10467-4111
US

V. Phone/Fax

Practice location:
  • Phone: 718-231-6700
  • Fax: 718-515-5454
Mailing address:
  • Phone: 718-231-6700
  • Fax: 718-515-5454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHAMA R KHAN
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 718-231-6700