Healthcare Provider Details

I. General information

NPI: 1144288077
Provider Name (Legal Business Name): SOUTH FORK MEDICAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 OLD TOWN ROAD
SOUTHAMPTON NY
11968
US

IV. Provider business mailing address

PO BOX 2340
SOUTHAMPTON NY
11969-2340
US

V. Phone/Fax

Practice location:
  • Phone: 631-283-2100
  • Fax: 631-283-5731
Mailing address:
  • Phone: 631-283-2100
  • Fax: 631-283-5731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL B ISRAEL
Title or Position: PRACTICES MANAGING MEMBER
Credential: MD
Phone: 631-283-2100