Healthcare Provider Details

I. General information

NPI: 1851367304
Provider Name (Legal Business Name): EAST END GERIATRIC & ADULT MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 07/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 ACKERLY POND LANE
SOUTHOLD NY
11971-3005
US

IV. Provider business mailing address

PO BOX 1437
SOUTHOLD NY
11971-0938
US

V. Phone/Fax

Practice location:
  • Phone: 631-765-1414
  • Fax: 631-765-1428
Mailing address:
  • Phone: 631-765-1414
  • Fax: 631-765-1428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number23013867
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JAY P SLOTKIN
Title or Position: PRESIDENT
Credential: MD
Phone: 631-765-1414