Healthcare Provider Details

I. General information

NPI: 1255483707
Provider Name (Legal Business Name): NORTH SHORE MEDICAL ACCELERATOR PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

989 W JERICHO TPKE
SMITHTOWN NY
11787-3203
US

IV. Provider business mailing address

989 W JERICHO TPKE
SMITHTOWN NY
11787-3203
US

V. Phone/Fax

Practice location:
  • Phone: 631-864-5600
  • Fax: 631-864-5612
Mailing address:
  • Phone: 631-864-5600
  • Fax: 631-864-5612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number16883
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number16883
License Number StateNY

VIII. Authorized Official

Name: RICHARD THOMAS BYRNES
Title or Position: VICE PRESIDENT/MEDICAL DIRECTOR
Credential: MD
Phone: 631-864-5600