Provider Demographics
NPI:1093984981
Name:CONCOURSE VILLAGE PRIMARY CARE PLLC
Entity Type:Organization
Organization Name:CONCOURSE VILLAGE PRIMARY CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MACENAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-402-4021
Mailing Address - Street 1:769 CONCOURSE VLG W
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-3801
Mailing Address - Country:US
Mailing Address - Phone:718-402-4021
Mailing Address - Fax:718-402-4023
Practice Address - Street 1:769 CONCOURSE VLG W
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-3801
Practice Address - Country:US
Practice Address - Phone:718-402-4021
Practice Address - Fax:718-402-4023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211364174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
JM0301AR0OtherBLUE CROSS/SHIELD