Healthcare Provider Details

I. General information

NPI: 1386890960
Provider Name (Legal Business Name): BORIS MATUSEVICH PHYSICIAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2008
Last Update Date: 08/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 MONTAUK HWY SUITE 3
WEST ISLIP NY
11795
US

IV. Provider business mailing address

1175 MONTAUK HWY SUITE 3
WEST ISLIP NY
11795
US

V. Phone/Fax

Practice location:
  • Phone: 631-669-1171
  • Fax: 631-669-1912
Mailing address:
  • Phone: 631-669-1171
  • Fax: 631-669-1912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number217094
License Number StateNY

VIII. Authorized Official

Name: DR. BORIS MATUSEVICH
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 631-669-1171