Basic Information
| Provider Information | |||||||||
| NPI: | 1811429327 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BETHPAGE MEDICAL PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O BOX 310 | ||||||||
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| City: | PLAINVIEW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164145865 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4150 SUNRISE HWY | ||||||||
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| City: | MASSAPEQUA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117585303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164146900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2017 | ||||||||
| LastUpdateDate: | 04/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | FARLEY | ||||||||
| AuthorizedOfficialFirstName: | BRIANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIAL COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5164145865 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
No ID Information.