1174556963 NPI number — ISLAND GASTROENTEROLOGY CONSULTANTS 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 1174556963 NPI number — ISLAND GASTROENTEROLOGY CONSULTANTS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ISLAND GASTROENTEROLOGY CONSULTANTS 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:
1174556963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 MONTAUK HWY
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
WEST ISLIP
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11795-4910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-669-1171
Provider Business Mailing Address Fax Number:
631-669-1912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 MONTAUK HWY
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
WEST ISLIP
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11795-4910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-669-1171
Provider Business Practice Location Address Fax Number:
631-669-1912
Provider Enumeration Date:
07/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARIWALLA
Authorized Official First Name:
RAJ
Authorized Official Middle Name:
Authorized Official Title or Position:
GASTROENTEROLOGIST
Authorized Official Telephone Number:
631-669-1171

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  143127 , 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)





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