Healthcare Provider Details

I. General information

NPI: 1811241631
Provider Name (Legal Business Name): GRAND CONCOURSE HEALTH WELLNESS MEDICAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2012
Last Update Date: 10/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2336 GRAND CONCOURSE
BRONX NY
10458-6903
US

IV. Provider business mailing address

2336 GRAND CONCOURSE
BRONX NY
10458-6903
US

V. Phone/Fax

Practice location:
  • Phone: 718-220-0439
  • Fax: 718-220-0489
Mailing address:
  • Phone: 718-220-0439
  • Fax: 718-220-0489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number260048
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number260048
License Number StateNY

VIII. Authorized Official

Name: DMITRY ILYEVSKY
Title or Position: PRESIDENT
Credential: MD
Phone: 718-220-0439