Provider Demographics
NPI:1205671583
Name:PRIMARY CARE PHYSICIAN SPECIALIST, PC
Entity type:Organization
Organization Name:PRIMARY CARE PHYSICIAN SPECIALIST, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:ELBA
Authorized Official - Last Name:ANDRADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-498-3635
Mailing Address - Street 1:482 WINDING RD N
Mailing Address - Street 2:
Mailing Address - City:ARDSLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10502-2702
Mailing Address - Country:US
Mailing Address - Phone:914-498-3635
Mailing Address - Fax:718-828-5029
Practice Address - Street 1:1927 WILLIAMSBRIDGE RD STE 1B
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1604
Practice Address - Country:US
Practice Address - Phone:718-828-1549
Practice Address - Fax:718-828-5029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-27
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04938047Medicaid