Basic Information
| Provider Information | |||||||||
| NPI: | 1285745851 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ISLAND INTERVENTIONAL CARDIOLOGY,P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1031 | ||||||||
| Address2: | |||||||||
| City: | PORT WASHINGTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110501031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166292472 | ||||||||
| FaxNumber: | 5166292452 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PORT WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | ROSLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115761353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164143041 | ||||||||
| FaxNumber: | 5163652648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | REHMAN | ||||||||
| AuthorizedOfficialFirstName: | ASIF | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5164143041 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 01771604 | 05 | NY | MEDICAID |