1861135139 NPI number — MR. RYAN ALEXANDER DOHERTY

Table of content: MR. RYAN ALEXANDER DOHERTY (NPI 1861135139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861135139 NPI number — MR. RYAN ALEXANDER DOHERTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOHERTY
Provider First Name:
RYAN
Provider Middle Name:
ALEXANDER
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1861135139
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
576 BROADHOLLOW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11747-5002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-359-5859
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
94 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAY SHORE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11706-8365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-983-3724
Provider Business Practice Location Address Fax Number:
631-223-4765
Provider Enumeration Date:
04/15/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  026682 , 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: 026682 . This is a "NEW YORK STATE OFFICE OF THE PROFESSIONS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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