Organization
BRONX BOROUGH MEDICAL PRACTICE PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MACK LEE SULLIVAN (OWNER)
(914) 395-3691
Entity
Organization
Contact information
Practice address
2494 WILLIAMSBRIDGE RD, BRONX, NY 10469-4806
(914) 395-3691
Mailing address
369 WHITE PLAINS RD STE B, EASTCHESTER, NY 10709-2805
(914) 395-3691
Taxonomy
Speciality
Code
Description
License number
State
207RS0010X
Sports Medicine (Internal Medicine) Physician
—
—
2081P2900X
Pain Medicine (Physical Medicine & Rehabilitation) Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
115019
LICENSE
NY
Enumeration date
12/21/2018
Last updated
12/21/2018
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