Basic Information
Provider Information | |||||||||
NPI: | 1427666437 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LONG ISLAND NEUROSCIENCE MEDICAL CONSULTING PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1175 MONTAUK HWY STE 6 | ||||||||
Address2: |   | ||||||||
City: | WEST ISLIP | ||||||||
State: | NY | ||||||||
PostalCode: | 117954939 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6314829977 | ||||||||
FaxNumber: | 6314673070 | ||||||||
Practice Location | |||||||||
Address1: | 1175 MONTAUK HWY STE 6 | ||||||||
Address2: |   | ||||||||
City: | WEST ISLIP | ||||||||
State: | NY | ||||||||
PostalCode: | 117954939 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6314829977 | ||||||||
FaxNumber: | 6314673070 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2020 | ||||||||
LastUpdateDate: | 06/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MULLINS | ||||||||
AuthorizedOfficialFirstName: | KEVIN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
AuthorizedOfficialTelephone: | 6314829977 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 06/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZE0600X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic |
No ID Information.