Healthcare Provider Details

I. General information

NPI: 1376734079
Provider Name (Legal Business Name): MERCY INTERNAL MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N. VILLAGE AVENUE
ROCKVILLE CENTRE NY
11571
US

IV. Provider business mailing address

P.O. BOX 798
ROCKVILLE CENTRE NY
11571
US

V. Phone/Fax

Practice location:
  • Phone: 516-705-1353
  • Fax:
Mailing address:
  • Phone: 516-705-1353
  • Fax: 516-705-3575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number178140
License Number StateNY

VIII. Authorized Official

Name: JOHN REILLY
Title or Position: DIRECOR
Credential: MD
Phone: 516-705-1353