Healthcare Provider Details

I. General information

NPI: 1144553025
Provider Name (Legal Business Name): VASCULAR INTERVENTIONAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110B HALLOCK AVE
PORT JEFFERSON STA NY
11776-1210
US

IV. Provider business mailing address

1110B HALLOCK AVENUE
PORT JEFFERSON STATION NY
11776-1210
US

V. Phone/Fax

Practice location:
  • Phone: 631-476-9100
  • Fax: 631-476-4919
Mailing address:
  • Phone: 631-476-9100
  • Fax: 631-476-4919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number193100
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number221708
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number099574
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number186340
License Number StateNY

VIII. Authorized Official

Name: DR. ROBERT M POLLINA
Title or Position: OWNER
Credential: M.D.
Phone: 631-476-9100