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General NPI Number Information
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NPI Number | 1396090932
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Entity Type | Organization
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Legal Business Name | SOUTHERN WELLCARE MEDICAL PC
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Dates
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Enumeration Date | 07/19/2012
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Last Update Date | 10/17/2019
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Provider Practice Location Address
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Address Line | 2336 GRAND CONCOURSE
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City | BRONX
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State | NY
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Zip | 10458-6903
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Country | US
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Telephone | 718-907-0195
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Fax |
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Provider Business Mailing Address
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Address Line | 2336 GRAND CONCOURSE
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City | BRONX
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State | NY
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Zip | 10458-6903
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Country | US
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Telephone | 718-220-0439
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Fax | 718-933-2914
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Authorized Official
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Title or Position | PRESIDENT
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Name | SVETLANA KHANDROS
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Credential | D.O.
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Telephone | 718-220-0439
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 228243
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License Number State | NY
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