1932431103 NPI number — EAST NORTHPORT MEDICAL CARE 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 1932431103 NPI number — EAST NORTHPORT MEDICAL CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST NORTHPORT MEDICAL CARE 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:
1932431103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
554 LARKFIELD RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
EAST NORTHPORT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11731-4205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-368-9166
Provider Business Mailing Address Fax Number:
631-368-5682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
554 LARKFIELD RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
EAST NORTHPORT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11731-4205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-368-9166
Provider Business Practice Location Address Fax Number:
631-368-5682
Provider Enumeration Date:
02/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ANTONUCCI
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
631-368-9166

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  226879 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 170689 , 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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