Basic Information
| Provider Information | |||||||||
| NPI: | 1962652685 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH NASSAU PHYSICIAN PRACTICE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 S CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | VALLEY STREAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115805443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166323350 | ||||||||
| FaxNumber: | 5166323355 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 S CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | VALLEY STREAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115805443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166323350 | ||||||||
| FaxNumber: | 5166323355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2008 | ||||||||
| LastUpdateDate: | 09/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | DATTA | ||||||||
| AuthorizedOfficialFirstName: | RAJIV | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5166323350 | ||||||||
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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 | 208600000X | 200879 | NY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 242239 | NY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 201327 | NY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.