Basic Information
| Provider Information | |||||||||
| NPI: | 1376655621 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BAY OBGYN PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH BAY OBSTETRICS GYNECOLOGY PC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 MONTAUK HWY | ||||||||
| Address2: | SOUTH BAY OBGYN PC | ||||||||
| City: | WEST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117954401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315872500 | ||||||||
| FaxNumber: | 6315870292 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 MONTAUK HWY | ||||||||
| Address2: | SOUTH BAY OBGYN PC | ||||||||
| City: | WEST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117954401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315872500 | ||||||||
| FaxNumber: | 6315870292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 05/03/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LESTER | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN PRESIDENT OF PC | ||||||||
| AuthorizedOfficialTelephone: | 6315872500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.