Healthcare Provider Details

I. General information

NPI: 1639110802
Provider Name (Legal Business Name): BEVERLY HANNAH ORTIZ M.D., F.A.C.O.G.,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 RIVERLEIGH AVE SUITE 2B
RIVERHEAD NY
11901
US

IV. Provider business mailing address

PO BOX 2407
RIVERHEAD NY
11901
US

V. Phone/Fax

Practice location:
  • Phone: 631-298-4655
  • Fax: 631-298-7569
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberME85320
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number199062
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: