Healthcare Provider Details

I. General information

NPI: 1821163403
Provider Name (Legal Business Name): BRONX EAR NOSE & THROAT ASSOCIATE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 WESTCHESTER AVE STE #204
BRONX NY
10461
US

IV. Provider business mailing address

3250 WESTCHESTER AVE STE #204
BRONX NY
10461
US

V. Phone/Fax

Practice location:
  • Phone: 718-409-2780
  • Fax: 718-409-2786
Mailing address:
  • Phone: 718-409-2780
  • Fax: 718-409-2786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number195521
License Number StateNY

VIII. Authorized Official

Name: LEACROFT GREEN
Title or Position: OWNER
Credential: MD
Phone: 718-409-2780