Healthcare Provider Details

I. General information

NPI: 1275810533
Provider Name (Legal Business Name): LONG ISLAND FERTILITY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2011
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 CORPORATE CENTER DR SUITE 101
MELVILLE NY
11747-3193
US

IV. Provider business mailing address

8 CORPORATE CENTER DR SUITE 101
MELVILLE NY
11747-3193
US

V. Phone/Fax

Practice location:
  • Phone: 631-752-0606
  • Fax: 631-331-1332
Mailing address:
  • Phone: 631-752-0606
  • Fax: 631-331-1332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number33D1081165
License Number StateNY

VIII. Authorized Official

Name: DIANE RAVECH
Title or Position: VICE PRESIDENT, MANAGED CARE
Credential: MPA
Phone: 860-678-3428