1619237807 NPI number — INFECTIOUS DISEASE CONSULTANT OF LONG ISLAND PC

Table of content: (NPI 1619237807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619237807 NPI number — INFECTIOUS DISEASE CONSULTANT OF LONG ISLAND PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INFECTIOUS DISEASE CONSULTANT OF LONG ISLAND 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:
1619237807
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 530
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JERICHO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11753-0530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-404-0493
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 NORTHERN BLVD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
MANHASSET
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11030-3037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-404-0493
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/21/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MARKOVSKAYA
Authorized Official First Name:
YELENA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO / OWNER
Authorized Official Telephone Number:
516-404-0493

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  222363 , 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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