1538451810 NPI number — SOVEREIGN MEDICAL SERVICES, PC

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 1538451810 NPI number — SOVEREIGN MEDICAL SERVICES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOVEREIGN MEDICAL 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:
1538451810
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 JERICHO TPKE
Provider Second Line Business Mailing Address:
SUITE 212
Provider Business Mailing Address City Name:
JERICHO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11753-1344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-277-2121
Provider Business Mailing Address Fax Number:
516-277-2122

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1050 5TH AVE
Provider Second Line Business Practice Location Address:
GROUND FLOOR
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10028-0110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-277-2121
Provider Business Practice Location Address Fax Number:
516-277-2122
Provider Enumeration Date:
05/05/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LANDOW
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
516-277-2121

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  184141 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X , with the licence number: 217344 , 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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