Healthcare Provider Details

I. General information

NPI: 1265627335
Provider Name (Legal Business Name): ISLAND MUSCULOSKELETAL CARE, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 10/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 N OCEAN AVE
PATCHOGUE NY
11772-1762
US

IV. Provider business mailing address

PO BOX 360
HEWLETT NY
11557-0360
US

V. Phone/Fax

Practice location:
  • Phone: 631-475-0353
  • Fax:
Mailing address:
  • Phone: 516-374-6838
  • Fax: 516-374-2362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNY
# 6
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. BARRY D JUPITER
Title or Position: PRESIDENT
Credential: MD
Phone: 516-374-6838