Healthcare Provider Details

I. General information

NPI: 1437247509
Provider Name (Legal Business Name): 1211 WPR MEDICAL SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/30/2021
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 WHITE PLAINS RD
BRONX NY
10472-4900
US

IV. Provider business mailing address

1211 WHITE PLAINS RD
BRONX NY
10472-4900
US

V. Phone/Fax

Practice location:
  • Phone: 718-082-8066
  • Fax: 718-829-9132
Mailing address:
  • Phone: 718-828-6610
  • Fax: 718-829-9132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0810561
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AMY CAROL POLAN
Title or Position: AM
Credential:
Phone: 718-828-6610