=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982243887
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDALLIANCE MEDICAL HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2019
-----------------------------------------------------
Last Update Date | 12/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5041 BROADWAY
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10034-1131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-869-2144
-----------------------------------------------------
Fax | 646-869-4955
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 E FORDHAM RD
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10458-5049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-933-1900
-----------------------------------------------------
Fax | 718-563-4039
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMIN ASSISTANT/ CREDENTIALING
-----------------------------------------------------
Name | MARISOL BRAVO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-933-1900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------