Basic Information
| Provider Information | |||||||||
| NPI: | 1881978021 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXCEL URGENT CARE OF EAST NORTHPORT, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 484 TEMPLE HILL RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | NEW WINDSOR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125535529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455653700 | ||||||||
| FaxNumber: | 8455653696 | ||||||||
| Practice Location | |||||||||
| Address1: | 558 LARKFIELD RD | ||||||||
| Address2: | |||||||||
| City: | EAST NORTHPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117314204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314867459 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2011 | ||||||||
| LastUpdateDate: | 10/26/2017 | ||||||||
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| AuthorizedOfficialLastName: | RUVO | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8455653700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | DU2258 | 01 | RAILROAD MEDICARE | OTHER | 03845907 | 05 | NY | MEDICAID |