Healthcare Provider Details

I. General information

NPI: 1326484478
Provider Name (Legal Business Name): ALIVE HEALTHCARE & MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2013
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 N OCEAN AVE
PATCHOGUE NY
11772-2004
US

IV. Provider business mailing address

11 ALYSSUM AVE
HUNTINGTON NY
11743-5606
US

V. Phone/Fax

Practice location:
  • Phone: 347-392-7208
  • Fax:
Mailing address:
  • Phone: 347-392-7208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. JAMIE ANDRE
Title or Position: CEO
Credential: MD
Phone: 347-392-7208