Provider Demographics
NPI:1891746368
Name:BOULEVARD MEDICAL HEALTHCARE
Entity type:Organization
Organization Name:BOULEVARD MEDICAL HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DIFAZIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-325-9532
Mailing Address - Street 1:4238 BRONX BLVD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-2611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4238 BRONX BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-2611
Practice Address - Country:US
Practice Address - Phone:718-743-7090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY151941207R00000X
NY130048207RA0201X
NY106848207RC0000X
NY105455207RG0100X
NY206326207RN0300X
NY123469207VG0400X
NY109441207W00000X
NY170475208000000X
NY120111208800000X
NYN003013213E00000X
NY177458111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & ImmunologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF88989Medicare UPIN
NYF96255Medicare UPIN
NYA59914Medicare UPIN
NYD72084Medicare UPIN
NYG70923Medicare UPIN
NYI19512Medicare UPIN
NYA61968Medicare UPIN
NYB18712Medicare UPIN
NYG30982Medicare UPIN
NYA61023Medicare UPIN
NYE64971Medicare UPIN
NY64K03EU641Medicare PIN
NYG04338Medicare UPIN
NYF58631Medicare UPIN
NYC06543Medicare UPIN
NYWEU641Medicare PIN
NY82G16EU641Medicare PIN
NYT50951Medicare UPIN
NYH25338Medicare UPIN