Provider Demographics
NPI:1235316563
Name:A.W MEDICAL OFFICE, P.C
Entity Type:Organization
Organization Name:A.W MEDICAL OFFICE, P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RAMON
Authorized Official - Middle Name:MODESTO
Authorized Official - Last Name:TALLAJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-294-4008
Mailing Address - Street 1:571 ACADEMY ST
Mailing Address - Street 2:STE GLE
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-5104
Mailing Address - Country:US
Mailing Address - Phone:212-567-0550
Mailing Address - Fax:212-567-6474
Practice Address - Street 1:1624 UNIVERSITY AVE.
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-6948
Practice Address - Country:US
Practice Address - Phone:718-294-4008
Practice Address - Fax:718-294-9466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204704207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY639AH1OtherBCBS
NY639AH1OtherBCBS