Healthcare Provider Details

I. General information

NPI: 1790938595
Provider Name (Legal Business Name): NORTH SHORE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2008
Last Update Date: 10/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 SOUTHDOWN RD
HUNTINGTON NY
11743-2538
US

IV. Provider business mailing address

21 SOUTHDOWN RD
HUNTINGTON NY
11743-2538
US

V. Phone/Fax

Practice location:
  • Phone: 631-351-3763
  • Fax: 631-385-8210
Mailing address:
  • Phone: 631-351-3763
  • Fax: 631-385-8210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: JANET STREET
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 631-351-3700