1033143995 NPI number — JOHN PALERMO PHYSICAN ASSISTANT

Table of content: JOHN PALERMO PHYSICAN ASSISTANT (NPI 1033143995)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033143995 NPI number — JOHN PALERMO PHYSICAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PALERMO
Provider First Name:
JOHN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAN ASSISTANT
Provider Gender Code:
M

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:
1033143995
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
369 EAST MAIN STREET
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
EAST ISLIP
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11730-2800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-581-4500
Provider Business Mailing Address Fax Number:
631-581-1689

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 NORTHERN BLVD
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
GREAT NECK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11021-4058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-466-9300
Provider Business Practice Location Address Fax Number:
516-466-9353
Provider Enumeration Date:
07/10/2006

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: 363AM0700X , with the licence number:  006768 , 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: ZH0WET0810 . This is a "GROUP NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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