Healthcare Provider Details

I. General information

NPI: 1154464949
Provider Name (Legal Business Name): BADRI NATH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 PHYLLIS DRIVE
PATCHOGUE NY
11772
US

IV. Provider business mailing address

4 PHYLLIS DRIVE
PATCHOGUE NY
11772
US

V. Phone/Fax

Practice location:
  • Phone: 631-289-4700
  • Fax: 631-289-4718
Mailing address:
  • Phone: 631-289-4700
  • Fax: 631-289-4718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number194796
License Number StateNY

VII. Legacy identifiers

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

# 1
Identifier020038452
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerRR MCR
# 2
IdentifierP773785
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerOXF
# 3
Identifier01762005
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer
# 4
Identifier4635221
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerCIGNA
# 5
Identifier2400686
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerGHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: