Healthcare Provider Details

I. General information

NPI: 1669633061
Provider Name (Legal Business Name): MID ISLAND ORTHOPEDICS & SPORTS MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 09/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MANETTO HILL RD SUITE 107
PLAINVIEW NY
11803-1311
US

IV. Provider business mailing address

100 MANETTO HILL RD SUITE 107
PLAINVIEW NY
11803-1311
US

V. Phone/Fax

Practice location:
  • Phone: 516-935-1234
  • Fax: 516-935-0280
Mailing address:
  • Phone: 516-935-1234
  • Fax: 516-935-0280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number155874
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. JEFFREY S SIDER
Title or Position: OWNER/OPERATOR
Credential: MD
Phone: 516-935-1234