Healthcare Provider Details

I. General information

NPI: 1881643542
Provider Name (Legal Business Name): GREAT NECK MEDICAL ASSOCIATES, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 03/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 MARCUS AVE SUITE 200
LAKE SUCCESS NY
11042
US

IV. Provider business mailing address

2 OHIO DR
LAKE SUCCESS NY
11042-1111
US

V. Phone/Fax

Practice location:
  • Phone: 516-608-6820
  • Fax: 516-608-6822
Mailing address:
  • Phone: 516-608-6820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT KELLMAN
Title or Position: ADMINISTRATOR
Credential: MD
Phone: 516-608-6820