Provider Demographics
NPI:1811241631
Name:GRAND CONCOURSE HEALTH WELLNESS MEDICAL, PC
Entity type:Organization
Organization Name:GRAND CONCOURSE HEALTH WELLNESS MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DMITRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ILYEVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-220-0439
Mailing Address - Street 1:2336 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-6903
Mailing Address - Country:US
Mailing Address - Phone:718-220-0439
Mailing Address - Fax:718-220-0489
Practice Address - Street 1:2336 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-6903
Practice Address - Country:US
Practice Address - Phone:718-220-0439
Practice Address - Fax:718-220-0489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY260048208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty