Healthcare Provider Details

I. General information

NPI: 1215601158
Provider Name (Legal Business Name): LONG ISLAND MEDICAL INTERVENTIONAL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4273 HEMPSTEAD TPKE
BETHPAGE NY
11714-5710
US

IV. Provider business mailing address

PO BOX 676
SYOSSET NY
11791-0676
US

V. Phone/Fax

Practice location:
  • Phone: 516-605-0600
  • Fax: 516-321-0713
Mailing address:
  • Phone: 516-605-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TRUSHA NARENDRA SHAH
Title or Position: CEO
Credential: MD
Phone: 516-605-0600