Healthcare Provider Details

I. General information

NPI: 1073698858
Provider Name (Legal Business Name): VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VA MEDICAL CENTER 79 MIDDLEVILLE RD - CARDIOLOGY 111
NORTHPORT NY
11768
US

IV. Provider business mailing address

50 SEQUOIA DR
CORAM NY
11727-2039
US

V. Phone/Fax

Practice location:
  • Phone: 631-261-4400
  • Fax:
Mailing address:
  • Phone: 631-474-0263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000277
License Number StateNY

VIII. Authorized Official

Name: MR. STEFAN MILLER
Title or Position: PHYSICIAN ASSISTANT
Credential: P.A.
Phone: 631-261-4400