Provider Demographics
NPI:1306249453
Name:MARK FROMER, LLC
Entity type:Organization
Organization Name:MARK FROMER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:FROMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-693-5738
Mailing Address - Street 1:3130 GRAND CONCOURSE
Mailing Address - Street 2:B5
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-1213
Mailing Address - Country:US
Mailing Address - Phone:917-693-5738
Mailing Address - Fax:417-889-2041
Practice Address - Street 1:3130 GRAND CONCOURSE
Practice Address - Street 2:B5
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-1213
Practice Address - Country:US
Practice Address - Phone:917-693-5738
Practice Address - Fax:417-889-2041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical