Basic Information
| Provider Information | |||||||||
| NPI: | 1104938455 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMMIRATA | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45 RESEARCH WAY STE 105 | ||||||||
| Address2: | UNIVERSITY ASSOCIATES OBGYN | ||||||||
| City: | EAST SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117336401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316728279 | ||||||||
| FaxNumber: | 6313507200 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 MONTAUK HIGHWAY | ||||||||
| Address2: | SOUTH BAY OB GYN PC | ||||||||
| City: | WEST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117954401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315872500 | ||||||||
| FaxNumber: | 6315870292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 10/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 2060531 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 01944912 | 05 | NY | MEDICAID | 2507203 | 01 | NY | GHI | OTHER | 44G631 | 01 | NY | BCBS | OTHER |