Provider Demographics
NPI:1023366861
Name:MARCO T HERNANDEZ PHYSICIAN PC
Entity Type:Organization
Organization Name:MARCO T HERNANDEZ PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE-BILLING MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-491-9410
Mailing Address - Street 1:1024 E 163RD ST
Mailing Address - Street 2:BRONX
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-4309
Mailing Address - Country:US
Mailing Address - Phone:718-542-6800
Mailing Address - Fax:718-842-3641
Practice Address - Street 1:1024 E 163RD ST
Practice Address - Street 2:BRONX
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-4309
Practice Address - Country:US
Practice Address - Phone:718-542-6800
Practice Address - Fax:718-842-3641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115852173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY115852OtherNYS LICENSE
NY641181Medicare UPIN