Healthcare Provider Details

I. General information

NPI: 1013350933
Provider Name (Legal Business Name): 866 MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2013
Last Update Date: 04/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

866 E TREMONT AVE
BRONX NY
10460-4201
US

IV. Provider business mailing address

866 E TREMONT AVE
BRONX NY
10460-4201
US

V. Phone/Fax

Practice location:
  • Phone: 347-515-0123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number217149
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number234017
License Number StateNY

VIII. Authorized Official

Name: DR. DANTE A CUBANGBANG
Title or Position: PRESIDENT
Credential: M.D
Phone: 917-930-9614