Provider Demographics
NPI:1821163403
Name:BRONX EAR NOSE & THROAT ASSOCIATE PC
Entity Type:Organization
Organization Name:BRONX EAR NOSE & THROAT ASSOCIATE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEACROFT
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-409-2780
Mailing Address - Street 1:3250 WESTCHESTER AVE
Mailing Address - Street 2:STE #204
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461
Mailing Address - Country:US
Mailing Address - Phone:718-409-2780
Mailing Address - Fax:718-409-2786
Practice Address - Street 1:3250 WESTCHESTER AVE
Practice Address - Street 2:STE #204
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461
Practice Address - Country:US
Practice Address - Phone:718-409-2780
Practice Address - Fax:718-409-2786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195521207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01677572Medicaid
NY456521Medicare ID - Type Unspecified
NY01677572Medicaid