Healthcare Provider Details

I. General information

NPI: 1548490063
Provider Name (Legal Business Name): ORTHOPAEDICS SPINE AND SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2009
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 EILEEN WAY
SYOSSET NY
11791-5323
US

IV. Provider business mailing address

115 EILEEN WAY
SYOSSET NY
11791-5323
US

V. Phone/Fax

Practice location:
  • Phone: 516-795-0333
  • Fax: 516-795-3036
Mailing address:
  • Phone: 516-795-3033
  • Fax: 516-795-3036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: NICOLE TASSO
Title or Position: MANAGER
Credential:
Phone: 516-795-3033