Healthcare Provider Details

I. General information

NPI: 1023134384
Provider Name (Legal Business Name): LONG ISLAND MEDICAL AND GASTROENTEROLOGY ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 E SHORE RD
GREAT NECK NY
11023-2416
US

IV. Provider business mailing address

192 E SHORE RD
GREAT NECK NY
11023-2416
US

V. Phone/Fax

Practice location:
  • Phone: 516-487-4500
  • Fax: 516-487-7439
Mailing address:
  • Phone: 516-487-4500
  • Fax: 516-487-7439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAELA S FAELLA
Title or Position: ADMINISTRATOR
Credential:
Phone: 516-650-4604