1386158764 NPI number — ISLAND RHEUMATOLOGY AND OSTEOPOROSIS, 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 1386158764 NPI number — ISLAND RHEUMATOLOGY AND OSTEOPOROSIS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ISLAND RHEUMATOLOGY AND OSTEOPOROSIS, 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:
1386158764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 960
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT JEFFERSON STATION
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11776-0813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-224-0905
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6144 ROUTE 25A STE 13
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WADING RIVER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-886-2488
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/22/2017

Additional Information

Authorized Official

Authorized Official Last Name:
GODHWANI
Authorized Official First Name:
SANJAY
Authorized Official Middle Name:
Authorized Official Title or Position:
RHEUMATOLOGIST/MEDICAL DIRECTOR
Authorized Official Telephone Number:
631-886-2844

Provider Taxonomy Codes

  • Taxonomy code: 207RR0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03497523 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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