Healthcare Provider Details

I. General information

NPI: 1417939653
Provider Name (Legal Business Name): DOREEN MARIE EADIE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 E PULASKI RD
HUNTINGTON STATION NY
11746-1915
US

IV. Provider business mailing address

180 E PULASKI RD
HUNTINGTON STATION NY
11746-1915
US

V. Phone/Fax

Practice location:
  • Phone: 631-425-2236
  • Fax: 631-425-2142
Mailing address:
  • Phone: 631-425-2236
  • Fax: 631-425-2142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007214
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: