=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023428455
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER SLAGUS M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2014
-----------------------------------------------------
Last Update Date | 12/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 48 ROUTE 25A STE 207
-----------------------------------------------------
City | SMITHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11787-1448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-862-3800
-----------------------------------------------------
Fax | 631-265-5520
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 MERCHANTS CONCOURSE STE 216
-----------------------------------------------------
City | WESTBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11590-5114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-226-8373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | 294675
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207VX0000X
-----------------------------------------------------
Taxonomy Name | Obstetrics Physician
-----------------------------------------------------
License Number | 294675
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 294675
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------