Healthcare Provider Details

I. General information

NPI: 1639572589
Provider Name (Legal Business Name): WINTHROP FACULTY MEDICAL AFFILIATES UNIVERSITY FACULTY PRACTICE CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 10/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MINEOLA BLVD SUITE 100
MINEOLA NY
11501-4064
US

IV. Provider business mailing address

700 HICKSVILLE RD SUITE 204
BETHPAGE NY
11714-3471
US

V. Phone/Fax

Practice location:
  • Phone: 516-663-3018
  • Fax: 516-663-9755
Mailing address:
  • Phone: 516-576-6106
  • Fax: 516-576-5801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. MICHAEL D AMMAZZALORSO
Title or Position: CO-PRESIDENT
Credential: M.D.
Phone: 516-663-8209