Provider Demographics
NPI:1649364639
Name:BODHI MEDICAL CARE, LLC
Entity type:Organization
Organization Name:BODHI MEDICAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MALACHOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:917-664-5607
Mailing Address - Street 1:330 W 58TH ST
Mailing Address - Street 2:SUITE #414
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1827
Mailing Address - Country:US
Mailing Address - Phone:212-624-0220
Mailing Address - Fax:212-624-0220
Practice Address - Street 1:330 W 58TH ST
Practice Address - Street 2:SUITE #414
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1827
Practice Address - Country:US
Practice Address - Phone:212-624-0220
Practice Address - Fax:212-624-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218135207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01857152Medicaid
NY01857152Medicaid