Provider Demographics
NPI:1659741387
Name:CONCORDE MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:CONCORDE MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCHETTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-614-0039
Mailing Address - Street 1:316 E 30TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-8366
Mailing Address - Country:US
Mailing Address - Phone:212-614-0039
Mailing Address - Fax:212-253-9631
Practice Address - Street 1:135 E 37TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3083
Practice Address - Country:US
Practice Address - Phone:212-683-8107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONCORDE MEDICAL GROUP PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-07
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006186261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWES531Medicare UPIN