1306841911 NPI number — SOUTH ISLAND MEDICAL CARE PC

Table of content: (NPI 1306841911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306841911 NPI number — SOUTH ISLAND MEDICAL CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH ISLAND MEDICAL CARE 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:
1306841911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
76 SOUTHAVEN AVE
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11763-3745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-447-8860
Provider Business Mailing Address Fax Number:
631-447-8862

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
76 SOUTHAVEN AVE
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11763-3745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-447-8860
Provider Business Practice Location Address Fax Number:
631-447-8862
Provider Enumeration Date:
06/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SALAM
Authorized Official First Name:
M HANI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/ SOLO PRACTICE
Authorized Official Telephone Number:
631-447-8860

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  207811 , 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: 5081A1 . This is a "EMPIRE BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 9569338 . This is a "CIGNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01770227 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 640938 . This is a "HEALTHCARE PARTNERS IPA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7082351 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P2666424 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 115904 . This is a "VYTRA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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