1932170255 NPI number — LONG ISLAND SURGICAL SPECIALIST, P.C.

Table of content: (NPI 1932170255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932170255 NPI number — LONG ISLAND SURGICAL SPECIALIST, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONG ISLAND SURGICAL SPECIALIST, P.C.
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:
1932170255
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
05/31/2006
NPI Reactivation Date:
08/02/2007

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
639 PORT WASHINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT WASHINGTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11050-3733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-883-2212
Provider Business Mailing Address Fax Number:
516-767-7064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
639 PORT WASHINGTON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT WASHINGTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11050-3733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-883-2212
Provider Business Practice Location Address Fax Number:
516-767-7064
Provider Enumeration Date:
01/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BERROYA
Authorized Official First Name:
RENATO
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
516-883-2212

Provider Taxonomy Codes

  • Taxonomy code: 302F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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