Healthcare Provider Details

I. General information

NPI: 1548574155
Provider Name (Legal Business Name): FIVE BOROUGHS MEDICAL ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 OSPREY AVENUE
RIVERHEAD NY
11901
US

IV. Provider business mailing address

PO BOX 158
PLAINVIEW NY
11803
US

V. Phone/Fax

Practice location:
  • Phone: 347-417-9081
  • Fax:
Mailing address:
  • Phone: 347-417-9081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number255627
License Number StateNY

VIII. Authorized Official

Name: BRIAN MARMOR
Title or Position: ADMINISTRATOR
Credential:
Phone: 718-629-5590