Healthcare Provider Details

I. General information

NPI: 1780071548
Provider Name (Legal Business Name): ISLAND MUSCULOSKELETAL CARE MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10825 JAMAICA AVE
RICHMOND HILL NY
11418-2243
US

IV. Provider business mailing address

PO BOX 360
HEWLETT NY
11557-0360
US

V. Phone/Fax

Practice location:
  • Phone: 516-374-6838
  • Fax: 516-374-2362
Mailing address:
  • Phone: 516-374-6838
  • Fax: 516-374-2362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. BARRY D JUPITER
Title or Position: PRESIDENT
Credential: MD
Phone: 516-374-6838