Healthcare Provider Details

I. General information

NPI: 1285748749
Provider Name (Legal Business Name): ISLAND MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 02/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4277 HEMPSTEAD TPKE SUITE 209
BETHPAGE NY
11714-5709
US

IV. Provider business mailing address

4277 HEMPSTEAD TPKE SUITE 209
BETHPAGE NY
11714-5709
US

V. Phone/Fax

Practice location:
  • Phone: 516-731-7770
  • Fax: 516-731-7052
Mailing address:
  • Phone: 516-731-7770
  • Fax: 516-731-7052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. SUSAN BRENNER-SMITH
Title or Position: BILLING MANAGER
Credential:
Phone: 516-731-7770