=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144020132
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRINE HEALTH MEDICAL GROUP, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2025
-----------------------------------------------------
Last Update Date | 03/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 ROCKAWAY AVE STE 212
-----------------------------------------------------
City | HEWLETT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11557-1677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-407-2727
-----------------------------------------------------
Fax | 516-387-9797
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 370 OLD COUNTRY RD STE 100
-----------------------------------------------------
City | GARDEN CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11530-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-407-2727
-----------------------------------------------------
Fax | 516-387-9797
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SIMON ELLIOT PRINCE
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 516-407-2727
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------