Healthcare Provider Details

I. General information

NPI: 1932170255
Provider Name (Legal Business Name): LONG ISLAND SURGICAL SPECIALIST, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date: 05/31/2006
Reactivation Date: 08/02/2007

III. Provider practice location address

639 PORT WASHINGTON BLVD
PORT WASHINGTON NY
11050-3733
US

IV. Provider business mailing address

639 PORT WASHINGTON BLVD
PORT WASHINGTON NY
11050-3733
US

V. Phone/Fax

Practice location:
  • Phone: 516-883-2212
  • Fax: 516-767-7064
Mailing address:
  • Phone: 516-883-2212
  • Fax: 516-767-7064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: DR. RENATO B BERROYA
Title or Position: OWNER
Credential: M.D., F.A.C.S.
Phone: 516-883-2212