1497086235 NPI number — ISLAND NEPHROLOGY PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497086235 NPI number — ISLAND NEPHROLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ISLAND NEPHROLOGY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497086235
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 FIELDHOUSE AVE
Provider Second Line Business Mailing Address:
EAST SETAUKET
Provider Business Mailing Address City Name:
EAST SETAUKET
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11733-1038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-456-4447
Provider Business Mailing Address Fax Number:
561-282-3238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 TECHNOLOGY DRIVE
Provider Second Line Business Practice Location Address:
SUITE-130
Provider Business Practice Location Address City Name:
EAST SETAUKET
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-479-3743
Provider Business Practice Location Address Fax Number:
561-282-3238
Provider Enumeration Date:
01/19/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HUSSAIN
Authorized Official First Name:
ASHFAQ
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
631-456-4447

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  197431 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7X4431 . This is a "BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 03250268 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".