Healthcare Provider Details

I. General information

NPI: 1720629454
Provider Name (Legal Business Name): INTERNATIONAL TRAVEL MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S SERVICE RD STE 212
ROSLYN HTS NY
11577-2118
US

IV. Provider business mailing address

200 S SERVICE RD STE 212
ROSLYN HTS NY
11577-2118
US

V. Phone/Fax

Practice location:
  • Phone: 516-626-2004
  • Fax: 516-626-2583
Mailing address:
  • Phone: 516-626-2518
  • Fax: 516-626-2583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. TATIANA SIMON
Title or Position: ADMINISTRATOR
Credential:
Phone: 516-626-2518