Provider Demographics
NPI:1437247509
Name:1211 WPR MEDICAL SERVICES PC
Entity Type:Organization
Organization Name:1211 WPR MEDICAL SERVICES PC
Other - Org Name:WESTCHESTER MEDICAL HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AM
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:POLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-828-6610
Mailing Address - Street 1:1211 WHITE PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10472-4900
Mailing Address - Country:US
Mailing Address - Phone:718-828-6610
Mailing Address - Fax:718-829-9132
Practice Address - Street 1:1211 WHITE PLAINS RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-4900
Practice Address - Country:US
Practice Address - Phone:718-082-8066
Practice Address - Fax:718-829-9132
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:1211 WPR MEDICAL PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-11
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
NY0810561207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02770029Medicaid
W38511Medicare ID - Type Unspecified