1407191364 NPI number — EAST END PHYSICIAN SERVICES PC

Table of content: (NPI 1407191364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407191364 NPI number — EAST END PHYSICIAN SERVICES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST END PHYSICIAN SERVICES 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:
1407191364
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1341
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHOLD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-765-4150
Provider Business Mailing Address Fax Number:
631-765-4688

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44210 COUNTY RD. 48
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHOLD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11971
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-765-4150
Provider Business Practice Location Address Fax Number:
631-765-4688
Provider Enumeration Date:
12/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SIMON
Authorized Official First Name:
LLOYD
Authorized Official Middle Name:
DOUGLAS
Authorized Official Title or Position:
PRESIDENT (CORPORATION)
Authorized Official Telephone Number:
631-765-4150

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  153210-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RA0401X , with the licence number: 153210-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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