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General NPI Number Information
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NPI Number | 1003121013
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Entity Type | Organization
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Legal Business Name | NORTH SHORE MEDICAL GROUP OF MT SINAI SCHOOL OF MEDICINE
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Dates
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Enumeration Date | 08/13/2010
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Last Update Date | 08/13/2010
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Provider Practice Location Address
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Address Line | 201 PORTION RD SUITE C
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City | LAKE RONKONKOMA
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State | NY
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Zip | 11779-4172
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Country | US
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Telephone | 631-585-5959
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Fax |
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Provider Business Mailing Address
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Address Line | 201 PORTION RD SUITE C
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City | LAKE RONKONKOMA
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State | NY
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Zip | 11779-4172
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Country | US
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Telephone | 631-585-5959
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | JANET STREET
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Credential |
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Telephone | 631-351-3703
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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