Provider Demographics
NPI:1588734230
Name:SOUTH YONKERS FAMILY MEDICINE
Entity type:Organization
Organization Name:SOUTH YONKERS FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CARIDAD
Authorized Official - Middle Name:
Authorized Official - Last Name:FRESNEDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-237-8282
Mailing Address - Street 1:30 KIMBALL AVE
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10704-4221
Mailing Address - Country:US
Mailing Address - Phone:914-237-8282
Mailing Address - Fax:914-237-8575
Practice Address - Street 1:701 W 177TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-6928
Practice Address - Country:US
Practice Address - Phone:212-928-6580
Practice Address - Fax:212-543-1620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190207174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========OtherTAX ID#