Healthcare Provider Details

I. General information

NPI: 1467943522
Provider Name (Legal Business Name): NORTH SHORE HEMATOLOGY ONCOLOGY ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2018
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 OLD COUNTRY RD BLDG 2
RIVERHEAD NY
11901
US

IV. Provider business mailing address

1500 ROUTE 112 STE 101
PORT JEFFERSON STATION NY
11776-8054
US

V. Phone/Fax

Practice location:
  • Phone: 631-751-3000
  • Fax: 631-509-6559
Mailing address:
  • Phone: 631-751-3000
  • Fax: 631-509-6559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QX0203X
TaxonomyRadiation Oncology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA DANDRAIA
Title or Position: CREDENTIALING COORDINATOR
Credential: CREDENTIALING
Phone: 631-751-3000