Healthcare Provider Details

I. General information

NPI: 1033149026
Provider Name (Legal Business Name): MID ISLAND PRIMARY MEDICAL CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HICKSVILLE RD SUITE 110
SEAFORD NY
11783-1300
US

IV. Provider business mailing address

850 HICKSVILLE RD SUITE 110
SEAFORD NY
11783-1300
US

V. Phone/Fax

Practice location:
  • Phone: 516-735-5454
  • Fax: 516-735-6121
Mailing address:
  • Phone: 516-735-5454
  • Fax: 516-735-6121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN CUSUMANO
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 516-735-5454