Healthcare Provider Details

I. General information

NPI: 1851761233
Provider Name (Legal Business Name): BALM OF GILEAD MEDICAL OFFICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2015
Last Update Date: 09/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4626 WHITE PLAINS RD
BRONX NY
10470-1610
US

IV. Provider business mailing address

4626 WHITE PLAINS RD
BRONX NY
10470-1610
US

V. Phone/Fax

Practice location:
  • Phone: 631-737-4168
  • Fax:
Mailing address:
  • Phone: 631-737-4168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number211144
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number211144
License Number StateNY

VIII. Authorized Official

Name: DR. GREGORY EMILI
Title or Position: OWNER
Credential: MD
Phone: 631-737-4168