Healthcare Provider Details

I. General information

NPI: 1225748494
Provider Name (Legal Business Name): 25A MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2022
Last Update Date: 11/29/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W SUFFOLK AVENUE UNIT G
CENTRAL ISLIP NY
11722-2430
US

IV. Provider business mailing address

100 W SUFFOLK AVENUE UNIT G
CENTRAL ISLIP NY
11722-2430
US

V. Phone/Fax

Practice location:
  • Phone: 631-993-5400
  • Fax: 518-712-1634
Mailing address:
  • Phone: 631-993-5400
  • Fax: 518-712-1634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY THEODORIS
Title or Position: OWNER
Credential:
Phone: 631-993-5400