Healthcare Provider Details

I. General information

NPI: 1669738746
Provider Name (Legal Business Name): ISLAND PHYSICIAN SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 N VILLAGE AVE SUITE 109
ROCKVILLE CENTRE NY
11570-1078
US

IV. Provider business mailing address

2000 N VILLAGE AVE SUITE 109
ROCKVILLE CENTRE NY
11570-1078
US

V. Phone/Fax

Practice location:
  • Phone: 516-678-4000
  • Fax: 516-678-9573
Mailing address:
  • Phone: 516-678-4000
  • Fax: 516-678-9573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number176675
License Number StateNY

VIII. Authorized Official

Name: NICHOLAS TARRICONE
Title or Position: OWNER
Credential: MD MHA FACOG
Phone: 516-678-4000