MEDICARE: GH PRIMARY CARE LLC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1851258651
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GH PRIMARY CARE LLC

Provider Business Mailing Address
First Line	:	878 VAN DUZER ST
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10304-1816
Country	:	US
Telephone Number	:
Fax Number	:	718-285-4124

Provider Business Practice Location Address
First Line	:	878 VAN DUZER ST
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10304-1816
Country	:	US
Telephone Number	:	646-339-2321
Fax Number	:	718-285-4124

Authorized Official
Title or Position	:	FNP-BC
Name	:	GWENDOLYN HERNANDEZ
Credential	:	DNP
Telephone Number	:	646-339-2321

Provider Enumeration Date	:	01/06/2026
Last Update Date	:	01/06/2026

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