Healthcare Provider Details

I. General information

NPI: 1780630657
Provider Name (Legal Business Name): LONG ISLAND NEUROLOGICAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 01/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 ROUTE 111. SUITE #102
SMITHTOWN NY
11787-4756
US

IV. Provider business mailing address

363 ROUTE 111. SUITE #102
SMITHTOWN NY
11787-4756
US

V. Phone/Fax

Practice location:
  • Phone: 631-780-6804
  • Fax: 631-780-6806
Mailing address:
  • Phone: 631-738-8300
  • Fax: 631-738-8500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number220993
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number016755
License Number StateNY

VIII. Authorized Official

Name: SAMIR HADDAD
Title or Position: PRESIDENT
Credential:
Phone: 631-780-6804