Healthcare Provider Details

I. General information

NPI: 1437496510
Provider Name (Legal Business Name): ISLAND MEN'S MEDICAL HEALTH PRACTICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2013
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 RICHMOND RD
STATEN ISLAND NY
10304-2313
US

IV. Provider business mailing address

1551 RICHMOND RD
STATEN ISLAND NY
10304-2313
US

V. Phone/Fax

Practice location:
  • Phone: 718-979-4350
  • Fax: 718-979-4825
Mailing address:
  • Phone: 718-979-4350
  • Fax: 718-979-4825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number097198
License Number StateNY

VIII. Authorized Official

Name: BARRY GORDON
Title or Position: PHYSICIAN
Credential: MD
Phone: 718-979-4350