Healthcare Provider Details

I. General information

NPI: 1548899883
Provider Name (Legal Business Name): ORTHOPEDIC LI, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 DEER PARK AVE
BABYLON NY
11702-2356
US

IV. Provider business mailing address

403 DEER PARK AVE
BABYLON NY
11702-2356
US

V. Phone/Fax

Practice location:
  • Phone: 631-661-2663
  • Fax: 631-321-4971
Mailing address:
  • Phone: 631-661-2663
  • Fax: 631-321-4971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SAILA DETORE
Title or Position: OWNER
Credential: DO
Phone: 631-358-1868