Basic Information
| Provider Information | |||||||||
| NPI: | 1578928933 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH NASSAU UROLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HEALTHY WAY | ||||||||
| Address2: | PHYSICIAN BILLING | ||||||||
| City: | OCEANSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115721551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162551616 | ||||||||
| FaxNumber: | 5162554672 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 W MERRICK RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | FREEPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115203743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168760102 | ||||||||
| FaxNumber: | 5168671857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2015 | ||||||||
| LastUpdateDate: | 12/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | BOGEN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5166323965 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH NASSAU COMMUNITIES HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.