1821319575 NPI number — HEALTHSOURCE MEDICAL SERVICES MEDFORD, PLLC

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 1821319575 NPI number — HEALTHSOURCE MEDICAL SERVICES MEDFORD, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHSOURCE MEDICAL SERVICES MEDFORD, 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:
1821319575
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3001 EXPRESS DR N
Provider Second Line Business Mailing Address:
SUITE 200C
Provider Business Mailing Address City Name:
ISLANDIA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11749-5301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-435-0110
Provider Business Mailing Address Fax Number:
631-435-4583

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1743 N OCEAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11763-2649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-758-3100
Provider Business Practice Location Address Fax Number:
631-758-3168
Provider Enumeration Date:
06/17/2010

Additional Information

Authorized Official

Authorized Official Last Name:
FOLAN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
631-435-0110

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  167755 , 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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