Provider Demographics
NPI:1972554285
Name:CONCILIUM MEDICAL, P.C.
Entity Type:Organization
Organization Name:CONCILIUM MEDICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YAROSLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:BUKHAROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-938-3564
Mailing Address - Street 1:8420 85TH AVE
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-1217
Mailing Address - Country:US
Mailing Address - Phone:718-805-6767
Mailing Address - Fax:
Practice Address - Street 1:1200 GRAVESEND NECK RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4256
Practice Address - Country:US
Practice Address - Phone:718-332-3555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221545207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02194865Medicaid
NYWWQ191Medicare PIN
NY02194865Medicaid