1497826606 NPI number — GLEN COVE FAMILY MEDICINE. PLLC

Table of content: DR. WAEL ALI MANSOUR ABDELMOTTALEB MD (NPI 1992373443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497826606 NPI number — GLEN COVE FAMILY MEDICINE. PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLEN COVE FAMILY MEDICINE. 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:
1497826606
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
70 GLEN ST
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
GLEN COVE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11542-2855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-671-1351
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29 GLEN COVE AVE
Provider Second Line Business Practice Location Address:
108
Provider Business Practice Location Address City Name:
GLEN COVE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11542-2831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-671-1351
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RIZZO
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
RONALD
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
516-671-1351

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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