Provider Demographics
NPI:1043518467
Name:BRONXCARE DR. MARTIN LUTHER KING JR. HEALTH CENTER
Entity Type:Organization
Organization Name:BRONXCARE DR. MARTIN LUTHER KING JR. HEALTH CENTER
Other - Org Name:BRONXCARE CROTONA PARK FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP-CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:G
Authorized Official - Last Name:DEMARCO
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:718-901-8600
Mailing Address - Street 1:1276 FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-3402
Mailing Address - Country:US
Mailing Address - Phone:718-901-8600
Mailing Address - Fax:718-293-1475
Practice Address - Street 1:1591 FULTON AVENUE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457
Practice Address - Country:US
Practice Address - Phone:718-901-8600
Practice Address - Fax:718-293-1475
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRONXCARE DR. MARTIN LUTHER KING JR HEALTH CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-09
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7000212R261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW0437OtherBLUE CROSS
NY03410597Medicaid
33-1020Medicare UPIN