Healthcare Provider Details

I. General information

NPI: 1417187485
Provider Name (Legal Business Name): LONG ISLAND MEDICAL OFFICE BASED SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 07/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1074 OLD COUNTRY RD
PLAINVIEW NY
11803-4918
US

IV. Provider business mailing address

1074 OLD COUNTRY RD
PLAINVIEW NY
11803-4918
US

V. Phone/Fax

Practice location:
  • Phone: 516-939-6695
  • Fax: 516-939-2392
Mailing address:
  • Phone: 516-939-6695
  • Fax: 516-939-2392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0006X
TaxonomyAmbulatory Fertility Facility
License Number1517981
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. DAVID KREINER
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 516-939-6695