1275833477 NPI number — MBODY MINIMALLY INVASIVE SURGERY, 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 1275833477 NPI number — MBODY MINIMALLY INVASIVE SURGERY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MBODY MINIMALLY INVASIVE SURGERY, 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:
1275833477
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
365 COUNTY ROAD 39A
Provider Second Line Business Mailing Address:
SUITE 11
Provider Business Mailing Address City Name:
SOUTHAMPTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11968-5284
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-591-3992
Provider Business Mailing Address Fax Number:
631-591-0206

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
365 COUNTY ROAD 39A
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
SOUTHAMPTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11968-5284
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-591-3992
Provider Business Practice Location Address Fax Number:
631-591-0206
Provider Enumeration Date:
10/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GABRIEL
Authorized Official First Name:
NICK
Authorized Official Middle Name:
H
Authorized Official Title or Position:
C.E.O. - MANAGING PARTNER
Authorized Official Telephone Number:
631-591-3992

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  200259 , 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)





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