Healthcare Provider Details

I. General information

NPI: 1518206366
Provider Name (Legal Business Name): BASUK MEDICAL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2013
Last Update Date: 07/15/2023
Certification Date: 07/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 UNION BLVD SUITE 1
BAY SHORE NY
11706-8030
US

IV. Provider business mailing address

2011 UNION BLVD SUITE 1
BAY SHORE NY
11706-8030
US

V. Phone/Fax

Practice location:
  • Phone: 631-666-2900
  • Fax: 631-666-2900
Mailing address:
  • Phone: 631-666-2900
  • Fax: 631-666-2900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EDWARD GOLDBERG
Title or Position: BOOKKEEPER
Credential:
Phone: 516-810-0561