1467666461 NPI number — SOUTHAMPTON MEDICAL PC

Table of content: (NPI 1467666461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467666461 NPI number — SOUTHAMPTON MEDICAL PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHAMPTON MEDICAL 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:
1467666461
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
425 COUNTY ROAD 39A
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
SOUTHAMPTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11968-5277
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-283-4048
Provider Business Mailing Address Fax Number:
631-283-5396

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 COUNTY ROAD 39A
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SOUTHAMPTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11968-5277
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-283-4048
Provider Business Practice Location Address Fax Number:
631-283-5396
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
SHOBHA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER MD
Authorized Official Telephone Number:
631-283-4048

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  203693 , 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: 01837663 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com