Healthcare Provider Details

I. General information

NPI: 1407844160
Provider Name (Legal Business Name): ISLAND MEDICAL SPECIALISTS, P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2627 HYLAN BLVD STE C
STATEN ISLAND NY
10306-4344
US

IV. Provider business mailing address

2627 HYLAN BLVD STE C
STATEN ISLAND NY
10306-4344
US

V. Phone/Fax

Practice location:
  • Phone: 718-351-1136
  • Fax: 718-667-9711
Mailing address:
  • Phone: 718-351-1136
  • Fax: 718-667-9711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNY

VIII. Authorized Official

Name: LORI GUTERMAN
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 718-876-6220