Healthcare Provider Details

I. General information

NPI: 1750577201
Provider Name (Legal Business Name): MID ISLAND INTERNAL MEDICINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 05/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 HAWKINS AVE
RONKONKOMA NY
11779-4243
US

IV. Provider business mailing address

709 HAWKINS AVE
RONKONKOMA NY
11779-2293
US

V. Phone/Fax

Practice location:
  • Phone: 631-588-0880
  • Fax: 631-588-0391
Mailing address:
  • Phone: 631-588-0880
  • Fax: 631-588-0391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number199922
License Number StateNY

VIII. Authorized Official

Name: JENNIFER E LIOTTA
Title or Position: OFFICE MANAGER
Credential:
Phone: 631-588-0880