Healthcare Provider Details

I. General information

NPI: 1942645247
Provider Name (Legal Business Name): BRONX COMMUNITY MEDICINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 09/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2676 GRAND CONCOURSE # A
BRONX NY
10458-4914
US

IV. Provider business mailing address

2676 GRAND CONCOURSE A
BRONX NY
10458-4914
US

V. Phone/Fax

Practice location:
  • Phone: 718-708-4040
  • Fax: 718-708-6040
Mailing address:
  • Phone: 718-708-4040
  • Fax: 718-708-6040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number266860
License Number StateNY

VIII. Authorized Official

Name: DR. YOHANNA MARIA OLIVO MERCEDES
Title or Position: MD
Credential:
Phone: 347-204-3437