Healthcare Provider Details

I. General information

NPI: 1003485202
Provider Name (Legal Business Name): PRINE HEALTH IPA, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2021
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 NORTHERN BLVD STE 101
MANHASSET NY
11030-3022
US

IV. Provider business mailing address

370 OLD COUNTRY RD STE 100
GARDEN CITY NY
11530-1702
US

V. Phone/Fax

Practice location:
  • Phone: 516-548-8192
  • Fax:
Mailing address:
  • Phone: 516-548-8192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: KRISTIN MERLO
Title or Position: PROVIDER RELATIONS
Credential:
Phone: 516-548-8192