Provider Demographics
NPI:1396008801
Name:1957 BRONX MEDICAL P.C.
Entity type:Organization
Organization Name:1957 BRONX MEDICAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ILYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMUGLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-842-2854
Mailing Address - Street 1:9924 64TH AVE
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9924 64TH AVE
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2645
Practice Address - Country:US
Practice Address - Phone:917-842-2854
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221943174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty