Healthcare Provider Details

I. General information

NPI: 1568451243
Provider Name (Legal Business Name): MASSAPEQUA GASTROENTEROLOGY ASSOC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HICKSVILLE RD SUITE #100
SEAFORD NY
11783
US

IV. Provider business mailing address

850 HICKSVILLE RD SUITE #100
SEAFORD NY
11783
US

V. Phone/Fax

Practice location:
  • Phone: 516-796-9000
  • Fax: 516-796-6360
Mailing address:
  • Phone: 516-796-9000
  • Fax: 516-796-6360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: JANICE A HERRON
Title or Position: OFFICE MGR
Credential:
Phone: 516-796-9000