Basic Information
| Provider Information | |||||||||
| NPI: | 1891150553 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WINTHROP COMMUNITY MEDICAL AFFILIATES | ||||||||
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| OtherOrganizationName: | BETHPAGE PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 HICKSVILLE RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | BETHPAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117143471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169375000 | ||||||||
| FaxNumber: | 5169312535 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 HICKSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BETHPAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117143415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165765822 | ||||||||
| FaxNumber: | 5165765801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2015 | ||||||||
| LastUpdateDate: | 12/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | RAGNO | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
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| AuthorizedOfficialTitleorPosition: | CO-PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5168772629 | ||||||||
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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 | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.