Healthcare Provider Details

I. General information

NPI: 1790716546
Provider Name (Legal Business Name): LONG ISLAND SURGERY P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 02/26/2014
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
IdentifierP773785
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerOXF
# 2
Identifier01762005
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer
# 3
Identifier5020361
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerSUFFOLK HEALTHPLAN
# 4
Identifier020038452
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerMCR RR

VIII. Authorized Official

Name: DR. BADRI P NATH
Title or Position: MD
Credential: MD
Phone: 631-289-4700