Healthcare Provider Details

I. General information

NPI: 1619077070
Provider Name (Legal Business Name): ISLIP PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 ISLIP AVE
ISLIP NY
11751
US

IV. Provider business mailing address

215 ISLIP AVE
ISLIP NY
11751
US

V. Phone/Fax

Practice location:
  • Phone: 631-277-0558
  • Fax: 631-277-0978
Mailing address:
  • Phone: 631-277-0558
  • Fax: 631-277-0978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number214816
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02022351
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: DR. AUDREY CHONG-GAYLE
Title or Position: PRESIDENT
Credential: M.D
Phone: 631-277-0558