Basic Information
Provider Information | |||||||||
NPI: | 1902969033 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CARDIOLOGY & INTERNAL MEDICINE OF LONG ISLAND | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 510 HICKSVILLE RD | ||||||||
Address2: |   | ||||||||
City: | MASSAPEQUA | ||||||||
State: | NY | ||||||||
PostalCode: | 117581203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5167952626 | ||||||||
FaxNumber: | 5167997451 | ||||||||
Practice Location | |||||||||
Address1: | 510 HICKSVILLE RD | ||||||||
Address2: |   | ||||||||
City: | MASSAPEQUA | ||||||||
State: | NY | ||||||||
PostalCode: | 117581203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5167952626 | ||||||||
FaxNumber: | 5167997451 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/19/2006 | ||||||||
LastUpdateDate: | 05/15/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DOOLEY | ||||||||
AuthorizedOfficialFirstName: | FRANCES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5167952626 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
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AuthorizedOfficialCredential: | ANP | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207RC0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207R00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.