Healthcare Provider Details

I. General information

NPI: 1831470939
Provider Name (Legal Business Name): THREE GRACES MEDICAL PRACTICE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 09/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 E 180TH ST
BRONX NY
10457-3304
US

IV. Provider business mailing address

550 E 180TH ST
BRONX NY
10457-3304
US

V. Phone/Fax

Practice location:
  • Phone: 718-933-0333
  • Fax: 718-933-0337
Mailing address:
  • Phone: 718-933-0333
  • Fax: 718-933-0337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number176524
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number176524
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number176524
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number176524
License Number StateNY

VIII. Authorized Official

Name: DR. MYRA WHITE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 718-933-0333