Provider Demographics
NPI:1225699648
Name:334 GRAND CONCOURSE MEDICAL PC
Entity Type:Organization
Organization Name:334 GRAND CONCOURSE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERROL
Authorized Official - Middle Name:C
Authorized Official - Last Name:MALLETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-841-7392
Mailing Address - Street 1:444 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-4013
Mailing Address - Country:US
Mailing Address - Phone:718-841-7392
Mailing Address - Fax:347-862-2711
Practice Address - Street 1:444 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-4013
Practice Address - Country:US
Practice Address - Phone:718-841-7392
Practice Address - Fax:347-862-2711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-26
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty