Provider Demographics
NPI:1174819171
Name:AVIV MEDICAL CARE PC
Entity Type:Organization
Organization Name:AVIV MEDICAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING EMPLOYEE
Authorized Official - Prefix:MS
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:PROSKUROVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-653-7100
Mailing Address - Street 1:2426 EASTCHESTER RD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-5947
Mailing Address - Country:US
Mailing Address - Phone:718-653-7100
Mailing Address - Fax:718-231-7529
Practice Address - Street 1:2426 EASTCHESTER RD
Practice Address - Street 2:SUITE 212
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-5947
Practice Address - Country:US
Practice Address - Phone:718-653-7100
Practice Address - Fax:718-231-7529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-28
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY248691207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY093923OtherPSC
NYA100052323Medicare PIN