1306196936 NPI number — PRIMARY MEDICAL ASSOCIATES OF LONG ISLAND PLLC

Table of content: (NPI 1306196936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306196936 NPI number — PRIMARY MEDICAL ASSOCIATES OF LONG ISLAND PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMARY MEDICAL ASSOCIATES OF LONG ISLAND 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:
1306196936
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
54 SUNNYSIDE BLVD STE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLAINVIEW
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11803-1517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-506-7776
Provider Business Mailing Address Fax Number:
516-719-0708

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
54 SUNNYSIDE BLVD STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLAINVIEW
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11803-1517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-506-7776
Provider Business Practice Location Address Fax Number:
516-719-0708
Provider Enumeration Date:
09/11/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LEVINSKAYA
Authorized Official First Name:
NATALIA
Authorized Official Middle Name:
Authorized Official Title or Position:
ATTENDING PHYSICIAN
Authorized Official Telephone Number:
516-506-7776

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  260076 , 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: 33D2057234 . This is a "CLIA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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