Basic Information
| Provider Information | |||||||||
| NPI: | 1770877953 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATTERSON | ||||||||
| FirstName: | JEROMY | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6851 JERICHO TPKE STE 150 | ||||||||
| Address2: | |||||||||
| City: | SYOSSET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117914462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167171817 | ||||||||
| FaxNumber: | 6312046446 | ||||||||
| Practice Location | |||||||||
| Address1: | 11602 QUEENS BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113757055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183011100 | ||||||||
| FaxNumber: | 7182613893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2011 | ||||||||
| LastUpdateDate: | 10/12/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 278937 | NY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1720357817 | 01 | NY | NYC SURGICAL ASSOCIATES | OTHER | 04680333 | 05 | NY | MEDICAID |