Healthcare Provider Details

I. General information

NPI: 1841406196
Provider Name (Legal Business Name): MONTEFIORRE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E 77TH ST BLACKHALL, 9TH FLOOR CARDIOLOGY
NEW YORK NY
10021-1850
US

IV. Provider business mailing address

527 WANTAGH AVE
WANTAGH NY
11793-2102
US

V. Phone/Fax

Practice location:
  • Phone: 212-434-2606
  • Fax:
Mailing address:
  • Phone: 631-871-4240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number010148-1
License Number StateNY

VIII. Authorized Official

Name: MISS MARIA DEL CARMEN LEON
Title or Position: PHYSICIAN ASSISTANT
Credential: PA
Phone: 631-871-4240