Basic Information
| Provider Information | |||||||||
| NPI: | 1669075651 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL SERVICES OF KIPS BAY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PATCHOGUE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117723114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163588100 | ||||||||
| FaxNumber: | 6316541474 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 GREAT NECK RD | ||||||||
| Address2: | |||||||||
| City: | GREAT NECK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110213357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164874464 | ||||||||
| FaxNumber: | 5164874980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2020 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | CUSACK | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 5163216058 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0401X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 2084N0400X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.