MEDICARE: BOULEVARD MEDICAL HEALTHCARE

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	207R00000X	Internal Medicine Physician	151941	NY
2	207RA0201X	Allergy & Immunology (Internal Medicine) Physician	130048	NY
3	207RC0000X	Cardiovascular Disease Physician	106848	NY
4	207RG0100X	Gastroenterology Physician	105455	NY
5	207RN0300X	Nephrology Physician	206326	NY
6	207VG0400X	Gynecology Physician	123469	NY
7	207W00000X	Ophthalmology Physician	109441	NY
8	208000000X	Pediatrics Physician	170475	NY
9	208800000X	Urology Physician	120111	NY
10	213E00000X	Podiatrist	N003013	NY
11	111NX0800X	Orthopedic Chiropractor	177458	NY

General Provider Information

NPI Number	:	1891746368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOULEVARD MEDICAL HEALTHCARE

Provider Business Mailing Address
First Line	:	4238 BRONX BLVD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10466-2611
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4238 BRONX BLVD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10466-2611
Country	:	US
Telephone Number	:	718-743-7090
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	LOUIS DIFAZIO
Credential	:
Telephone Number	:	718-325-9532

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	03/16/2020

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Directions to “BOULEVARD MEDICAL HEALTHCARE ” Practice Location

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