# GRAND CONCOURSE HEALTH WELLNESS MEDICAL, PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1811241631
- **Authorized official:** DMITRY ILYEVSKY MD (PRESIDENT)
- **Authorized official phone:** (718) 220-0439

## Contact information

- **Practice address:** 2336 GRAND CONCOURSE, BRONX, NY 10458-6903
- **Practice address phone:** (718) 220-0439
- **Practice address fax:** (718) 220-0489
- **Mailing address:** 2336 GRAND CONCOURSE, BRONX, NY 10458-6903
- **Mailing address phone:** (718) 220-0439
- **Mailing address fax:** (718) 220-0489

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207R00000X | Internal Medicine Physician | 260048 | NY | Yes |
| 208000000X | Pediatrics Physician | 260048 | NY | — |

## Other

- **Enumeration date:** 10/31/2012
- **Last updated:** 10/31/2012