Healthcare Provider Details

I. General information

NPI: 1487984522
Provider Name (Legal Business Name): LAKE SUCCESS NEUROLOGICAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2010
Last Update Date: 01/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1991 MARCUS AVE SUITE 108
NEW HYDE PARK NY
11042-2057
US

IV. Provider business mailing address

1991 MARCUS AVE SUITE 108
NEW HYDE PARK NY
11042-2057
US

V. Phone/Fax

Practice location:
  • Phone: 516-442-2250
  • Fax: 516-442-1897
Mailing address:
  • Phone: 516-442-2250
  • Fax: 516-442-1897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0500X
TaxonomyEEG Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL H BRISMAN
Title or Position: CEO
Credential: M.D.
Phone: 516-255-9031