Basic Information
| Provider Information | |||||||||
| NPI: | 1841572096 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONG ISLAND MEDICAL PRACTICE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 GREENTREE CIR | ||||||||
| Address2: | |||||||||
| City: | WESTBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115901510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165037032 | ||||||||
| FaxNumber: | 5163385324 | ||||||||
| Practice Location | |||||||||
| Address1: | 41 GREENTREE CIR | ||||||||
| Address2: | |||||||||
| City: | WESTBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115901510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165037032 | ||||||||
| FaxNumber: | 5163385324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2011 | ||||||||
| LastUpdateDate: | 09/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | KOUL | ||||||||
| AuthorizedOfficialFirstName: | RAKESH | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5165037032 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.