Provider Demographics
NPI:1619973518
Name:PERRY AVE FAMILY MEDICAL CENTER INC
Entity Type:Organization
Organization Name:PERRY AVE FAMILY MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAMA
Authorized Official - Middle Name:R
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-231-6700
Mailing Address - Street 1:3071 PERRY AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-4111
Mailing Address - Country:US
Mailing Address - Phone:718-231-6700
Mailing Address - Fax:718-515-5454
Practice Address - Street 1:3071 PERRY AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-4111
Practice Address - Country:US
Practice Address - Phone:718-231-6700
Practice Address - Fax:718-515-5454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02444553Medicaid
NY2000416OtherGHI
NY7829562OtherAETNA
NYS70F11OtherBLUE CROSS
NY041227000012OtherFIDELIS
NY2478450OtherUNITED HEALTH CARE