MEDICARE: CCN GENERAL MEDICINE PLLC

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	207Q00000X	Family Medicine Physician
2	207R00000X	Internal Medicine Physician
3	261QP2300X	Primary Care Clinic/Center	255626	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1427118140	OTHER	NY	NPI

General Provider Information

NPI Number	:	1902120025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CCN GENERAL MEDICINE PLLC

Provider Business Mailing Address
First Line	:	1262 BOSTON RD
Second Line	:	SUITE 2
City	:	BRONX
State	:	NY
Zip	:	10456-3602
Country	:	US
Telephone Number	:	718-569-7929
Fax Number	:

Provider Business Practice Location Address
First Line	:	1262 BOSTON RD
Second Line	:	SUITE 2
City	:	BRONX
State	:	NY
Zip	:	10456-3602
Country	:	US
Telephone Number	:	718-569-7929
Fax Number	:	347-590-5482

Authorized Official
Title or Position	:	ADM
Name	:	HECTOR D REYES
Credential	:	MBA
Telephone Number	:	718-569-7929

Provider Enumeration Date	:	03/18/2010
Last Update Date	:	03/23/2026

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Directions to “CCN GENERAL MEDICINE PLLC ” Practice Location

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