Provider Demographics
NPI:1982243887
Name:MEDALLIANCE MEDICAL HEALTH SERVICES
Entity Type:Organization
Organization Name:MEDALLIANCE MEDICAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN ASSISTANT/ CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MARISOL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-933-1900
Mailing Address - Street 1:625 E FORDHAM RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-5049
Mailing Address - Country:US
Mailing Address - Phone:718-933-1900
Mailing Address - Fax:718-563-4039
Practice Address - Street 1:5041 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-1131
Practice Address - Country:US
Practice Address - Phone:646-869-2144
Practice Address - Fax:646-869-4955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty