1295911741 NPI number — SOUTH FORK GYNECOLOGY

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 1295911741 NPI number — SOUTH FORK GYNECOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH FORK GYNECOLOGY
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:
1295911741
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 PANTIGO PLACE
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
EAST HAMPTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11937
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-329-6500
Provider Business Mailing Address Fax Number:
631-329-7832

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 PANTIGO PLACE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
EAST HAMPTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-329-6500
Provider Business Practice Location Address Fax Number:
631-329-7832
Provider Enumeration Date:
01/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
COLLINS
Authorized Official First Name:
LOUISE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT PHYSICIAN
Authorized Official Telephone Number:
631-329-6500

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X , with the licence number:  221321 , 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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