Healthcare Provider Details

I. General information

NPI: 1366864514
Provider Name (Legal Business Name): GREAT SOUTH BAY ENDOSCOPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 PATCHOGUE YAPHANK RD SUITE C
EAST PATCHOGUE NY
11772-4886
US

IV. Provider business mailing address

260 PATCHOGUE YAPHANK RD STE C
EAST PATCHOGUE NY
11772-4886
US

V. Phone/Fax

Practice location:
  • Phone: 631-307-9181
  • Fax: 631-312-9187
Mailing address:
  • Phone: 631-307-9181
  • Fax: 631-312-9187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALICIA MOHAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 631-307-9181