1497702617 NPI number — COMMACK COMPREHENSIVE PEDIATRICS PLLC

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 1497702617 NPI number — COMMACK COMPREHENSIVE PEDIATRICS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMACK COMPREHENSIVE PEDIATRICS 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:
1497702617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2171 JERICHO TPKE
Provider Second Line Business Mailing Address:
SUITE 342
Provider Business Mailing Address City Name:
COMMACK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11725-2937
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-499-3588
Provider Business Mailing Address Fax Number:
631-499-3583

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
283 COMMACK RD
Provider Second Line Business Practice Location Address:
SUITE 325
Provider Business Practice Location Address City Name:
COMMACK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11725-6021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-499-3588
Provider Business Practice Location Address Fax Number:
631-499-3583
Provider Enumeration Date:
05/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAZUR
Authorized Official First Name:
BRITTA
Authorized Official Middle Name:
KAREEN
Authorized Official Title or Position:
PEDIATRICIAN
Authorized Official Telephone Number:
631-499-3588

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  188094 , 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: 01600215 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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