Healthcare Provider Details

I. General information

NPI: 1407939374
Provider Name (Legal Business Name): NORTH SHORE INTERNAL MEDICINE ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 12/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 NORTHERN BLVD SUITE 203
GREAT NECK NY
11021-5100
US

IV. Provider business mailing address

560 NORTHERN BLVD SUITE 203
GREAT NECK NY
11021-5100
US

V. Phone/Fax

Practice location:
  • Phone: 516-482-0600
  • Fax: 516-829-9674
Mailing address:
  • Phone: 516-482-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: JODIE BLOOM-GOLDSTEIN
Title or Position: BILLING COORDINATOR
Credential:
Phone: 516-482-0600