Healthcare Provider Details

I. General information

NPI: 1467826594
Provider Name (Legal Business Name): SIUC MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2015
Last Update Date: 09/02/2025
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

932 SOUTHERN BOULEVARD
BRONX NY
10459
US

IV. Provider business mailing address

C/O ADVANTAGECARE PHYSICIANS, PC 55 WATER ST 2ND FLOOR
NEW YORK NY
10041-0004
US

V. Phone/Fax

Practice location:
  • Phone: 646-680-5200
  • Fax:
Mailing address:
  • Phone: 646-680-2888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NAVARRA RODRIGUEZ
Title or Position: PRESIDENT
Credential: MD
Phone: 646-680-2888