Healthcare Provider Details

I. General information

NPI: 1346692639
Provider Name (Legal Business Name): ISLAND FOOT AND ANKLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

952 ROANOKE AVE
RIVERHEAD NY
11901-2734
US

IV. Provider business mailing address

1111 MONTAUK HWY
WEST ISLIP NY
11795-4910
US

V. Phone/Fax

Practice location:
  • Phone: 631-727-3592
  • Fax: 631-727-8892
Mailing address:
  • Phone: 631-422-4450
  • Fax: 631-422-4451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: EDWARD MCLAUGHLIN
Title or Position: PARTNER
Credential: DPM
Phone: 631-422-4450