Healthcare Provider Details

I. General information

NPI: 1558356741
Provider Name (Legal Business Name): MEDALLIANCE MEDICAL HEALTH SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E FORDHAM RD
BRONX NY
10458-5049
US

IV. Provider business mailing address

625 E FORDHAM RD
BRONX NY
10458-5049
US

V. Phone/Fax

Practice location:
  • Phone: 718-933-1900
  • Fax: 718-563-4039
Mailing address:
  • Phone: 718-933-1900
  • Fax: 718-563-4039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number0261903
License Number StateNY

VIII. Authorized Official

Name: MR. SHAHRIAR DANESHVAR
Title or Position: CEO
Credential: CASC
Phone: 718-933-1900