1174389225 NPI number — COMPREHENSIVE PROFESSIONAL MEDICAL PLLC

Table of content: (NPI 1174389225)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174389225 NPI number — COMPREHENSIVE PROFESSIONAL MEDICAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPREHENSIVE PROFESSIONAL MEDICAL PLLC
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:
1174389225
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 LEGENDS CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11747-5302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-776-6332
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
52 E ROUTE 59
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NANUET
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10954-2903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-619-9341
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/26/2024

Additional Information

Authorized Official

Authorized Official Last Name:
GRINMAN
Authorized Official First Name:
LEV
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
646-673-1660

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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