Provider Demographics
NPI:1710156211
Name:BETHEL MEDICAL PRACTICE P.C
Entity Type:Organization
Organization Name:BETHEL MEDICAL PRACTICE P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINGO
Authorized Official - Middle Name:ANTHONIO
Authorized Official - Last Name:SANTANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-676-4177
Mailing Address - Street 1:2160 ANTHONY AVE
Mailing Address - Street 2:APT # 4F
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457
Mailing Address - Country:US
Mailing Address - Phone:646-463-7552
Mailing Address - Fax:
Practice Address - Street 1:2869 GRAND CONCORSE
Practice Address - Street 2:SUITE # 1
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468
Practice Address - Country:US
Practice Address - Phone:718-676-4177
Practice Address - Fax:718-676-4179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239271261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI525338Medicare UPIN