Healthcare Provider Details

I. General information

NPI: 1104270198
Provider Name (Legal Business Name): NASSAU MEDICAL HOME VISITS P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2016
Last Update Date: 06/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 QUEENS ST SUITE 100
SYOSSET NY
11791-3058
US

IV. Provider business mailing address

60 QUEENS ST SUITE 100
SYOSSET NY
11791-3058
US

V. Phone/Fax

Practice location:
  • Phone: 631-271-9151
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GRIGORIY KRICHMAR
Title or Position: OWNER
Credential:
Phone: 631-271-9151