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General NPI Number Information
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NPI Number | 1093984981
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Entity Type | Organization
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Legal Business Name | CONCOURSE VILLAGE PRIMARY CARE PLLC
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Dates
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Enumeration Date | 02/25/2008
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Last Update Date | 02/25/2008
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Provider Practice Location Address
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Address Line | 769 CONCOURSE VLG W
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City | BRONX
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State | NY
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Zip | 10451-3801
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Country | US
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Telephone | 718-402-4021
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Fax | 718-402-4023
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Provider Business Mailing Address
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Address Line | 769 CONCOURSE VLG W
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City | BRONX
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State | NY
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Zip | 10451-3801
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Country | US
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Telephone | 718-402-4021
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Fax | 718-402-4023
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JEAN R. MACENAT
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Credential |
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Telephone | 718-402-4021
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 211364
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License Number State | NY
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