1538100631 NPI number — LONG ISLAND KIDNEY PHYSICIANS 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 1538100631 NPI number — LONG ISLAND KIDNEY PHYSICIANS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONG ISLAND KIDNEY PHYSICIANS 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:
1538100631
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:
PO BOX 1199
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
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33 WALT WHITMAN RD
Provider Second Line Business Practice Location Address:
SUITE 235
Provider Business Practice Location Address City Name:
HUNTINGTON STATION
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
635-549-1480
Provider Business Practice Location Address Fax Number:
631-549-2511
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YUN
Authorized Official First Name:
SUK-HYEON
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
631-549-1480

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02299470 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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