=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396008801
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1957 BRONX MEDICAL P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2012
-----------------------------------------------------
Last Update Date | 06/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9924 64TH AVE
-----------------------------------------------------
City | REGO PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11374-2645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-842-2854
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9924 64TH AVE
-----------------------------------------------------
City | REGO PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11374-2645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. ILYA SMUGLIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 917-842-2854
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 221943
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------