MEDICARE: GASTROENTEROLOGY AND LIVER DISEASE OF THE BRONX, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician

General Provider Information

NPI Number	:	1508052846
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GASTROENTEROLOGY AND LIVER DISEASE OF THE BRONX, P.C.

Provider Business Mailing Address
First Line	:	1180 MORRIS PARK AVE
Second Line	:	3RD FLOOR
City	:	BRONX
State	:	NY
Zip	:	10461-1925
Country	:	US
Telephone Number	:	718-879-6600
Fax Number	:	718-892-6594

Provider Business Practice Location Address
First Line	:	1180 MORRIS PARK AVE
Second Line	:	3RD FLOOR
City	:	BRONX
State	:	NY
Zip	:	10461-1925
Country	:	US
Telephone Number	:	718-879-6600
Fax Number	:	718-892-6594

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK I. RUBIN
Credential	:	M.D.
Telephone Number	:	718-879-6600

Provider Enumeration Date	:	09/20/2007
Last Update Date	:	04/20/2008

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