Healthcare Provider Details

I. General information

NPI: 1841617412
Provider Name (Legal Business Name): PLATINUM FAMILY MEDICINE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2014
Last Update Date: 03/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 ROUTE 25A
MILLER PLACE NY
11764-2649
US

IV. Provider business mailing address

765 ROUTE 25A
MILLER PLACE NY
11764-2649
US

V. Phone/Fax

Practice location:
  • Phone: 631-849-5900
  • Fax: 631-849-5897
Mailing address:
  • Phone: 631-849-5900
  • Fax: 631-849-5897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1995901
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number1995901
License Number StateNY

VIII. Authorized Official

Name: DR. JOSEPH VENEZIA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 631-675-1919