NPIMap

Organization Active NPI

Bronxcare Dr. Martin Luther King Jr. Health Center

Doing business as BronxCare Dental Services

  • Federally Qualified Health Center (FQHC)
  • Bronx, NY
National Provider Identifier
1619275039
Registry record updated Jun 28, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
7000212R Issued in NY
Legal business name
BRONXCARE DR. MARTIN LUTHER KING JR. HEALTH CENTER
Doing business as
BronxCare Dental Services
Practice address
1775 Grand Concourse
Bronx, NY 10453
Phone
(718) 901-8600
Fax
(718) 293-1475
NPI assigned
Mar 9, 2011
Last updated
Jun 28, 2018By the provider in NPPES
Organization subpart
Yes
Parent organization
BRONXCARE DR. MARTIN LUTHER KING JR HEALTH CENTER INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 28, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Victor G Demarco, CPA
Title
Senior VP-Chief Financial Officer
Phone
(718) 901-8600

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 7000212R NY Primary

Addresses

Primary practice location

1775 Grand Concourse
Bronx, NY 10453

Mailing address

1276 Fulton Ave
Bronx, NY 10456-3402
Phone (718) 901-8600

Other identifiers 2

IdentifierTypeStateIssuer
03410919MedicaidNY
W0437OtherNYBLUE CROSS

Other names 1

  • BronxCare Dental Services Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110329000750 NY Part A Provider - Federally Qualified Health Center (FQHC) 7214847243 Practice locations: Bronx, NY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1619275039. Details of each certification follow.

Federally qualified health center certification: CCN 331023

Legal name
BRONXCARE DR MARTIN LUTHER KING JR HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 19, 2011
Last certification
May 19, 2011
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1972 in NY
Enrollment address
1775 Grand Concourse
Bronx, NY 10453-8202

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Martin L King HLTH Ctr7 organizations share this tax ID, including this one
Part of
Martin L King HLTH Ctr

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 7

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Vaughn L. Thomas Individual Corporate DirectorBoard Member Apr 26, 2007
Ellen R Hoist Individual Corporate DirectorBoard Member May 24, 2007
Martha Reyes Individual Corporate DirectorBoard Member Apr 23, 2003
Robert a. Carrillo Individual Corporate DirectorBoard Member Nov 19, 2009
Julio Pabon Individual Corporate DirectorBoard Member Apr 26, 2007
Luis Francisco Individual W-2 Managing EmployeeIt Manager Oct 3, 2016
Victor G Demarco Individual Corporate OfficerSenior Vice President & Chief Fi Nov 1, 1999

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1299628800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1530144000000",
    "number": "1619275039",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1276 FULTON AVE",
            "city": "BRONX",
            "state": "NY",
            "postal_code": "104563402",
            "telephone_number": "718-901-8600",
            "fax_number": "718-293-1475"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1775 GRAND CONCOURSE",
            "city": "BRONX",
            "state": "NY",
            "postal_code": "10453",
            "telephone_number": "718-901-8600",
            "fax_number": "718-293-1475"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BRONXCARE DR. MARTIN LUTHER KING JR. HEALTH CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "BRONXCARE DR. MARTIN LUTHER KING JR HEALTH CENTER INC",
        "enumeration_date": "2011-03-09",
        "last_updated": "2018-06-28",
        "status": "A",
        "authorized_official_last_name": "DEMARCO",
        "authorized_official_first_name": "VICTOR",
        "authorized_official_middle_name": "G",
        "authorized_official_title_or_position": "SENIOR VP-CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "718-901-8600",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "CPA"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NY",
            "license": "7000212R",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "03410919",
            "state": "NY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "W0437",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "BronxCare Dental Services",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Bronx, NY

Sources for this page

Verify at the official NPI Registry.