Healthcare Provider Details

I. General information

NPI: 1629124003
Provider Name (Legal Business Name): NORTH BRONX UROLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2016 BRONXDALE AVE
BRONX NY
10462-3388
US

IV. Provider business mailing address

1100 SHAMES DR
WESTBURY NY
11590-1765
US

V. Phone/Fax

Practice location:
  • Phone: 718-863-8695
  • Fax: 718-863-5147
Mailing address:
  • Phone: 516-693-0700
  • Fax: 516-693-0271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number196895
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01977513
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: KATHY BAEZ
Title or Position: COO
Credential:
Phone: 516-693-0700