1538224654 NPI number — MAUREEN MCKEON-SIMONE RD

Table of content: MAUREEN MCKEON-SIMONE RD (NPI 1538224654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538224654 NPI number — MAUREEN MCKEON-SIMONE RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKEON-SIMONE
Provider First Name:
MAUREEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

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:
1538224654
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27 LANIER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAY SHORE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11706-7825
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:
4 SMITH HAVEN MALL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE GROVE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11755-1219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-444-1933
Provider Business Practice Location Address Fax Number:
631-444-7248
Provider Enumeration Date:
12/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X , with the licence number: 2600 , 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)