Provider Demographics
NPI:1811943228
Name:MIGRACE MEDICAL PRACTICE PC
Entity type:Organization
Organization Name:MIGRACE MEDICAL PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AVILA-RONDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-862-9046
Mailing Address - Street 1:PO BOX 1828
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-8801
Mailing Address - Country:US
Mailing Address - Phone:212-862-9046
Mailing Address - Fax:
Practice Address - Street 1:982 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-2501
Practice Address - Country:US
Practice Address - Phone:212-862-9046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193694174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY48C311Medicare ID - Type Unspecified