Healthcare Provider Details

I. General information

NPI: 1407191364
Provider Name (Legal Business Name): EAST END PHYSICIAN SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2012
Last Update Date: 06/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44210 COUNTY RD. 48
SOUTHOLD NY
11971
US

IV. Provider business mailing address

P.O. BOX 1341
SOUTHOLD NY
11971
US

V. Phone/Fax

Practice location:
  • Phone: 631-765-4150
  • Fax: 631-765-4688
Mailing address:
  • Phone: 631-765-4150
  • Fax: 631-765-4688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number153210-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number153210-1
License Number StateNY

VIII. Authorized Official

Name: DR. LLOYD DOUGLAS SIMON
Title or Position: PRESIDENT (CORPORATION)
Credential: MD
Phone: 631-765-4150