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General NPI Number Information
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NPI Number | 1174602189
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Entity Type | Organization
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Legal Business Name | EASTERN SUFFOLK NEPHROLOGY, PC
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Dates
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Enumeration Date | 11/02/2006
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Last Update Date | 06/18/2008
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Provider Practice Location Address
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Address Line | 758 HARRISON AVE
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City | RIVERHEAD
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State | NY
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Zip | 11901-2744
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Country | US
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Telephone | 631-727-5112
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Fax | 631-727-9061
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Provider Business Mailing Address
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Address Line | 758 HARRISON AVE
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City | RIVERHEAD
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State | NY
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Zip | 11901-2744
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Country | US
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Telephone | 631-727-5112
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Fax | 631-727-9061
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Authorized Official
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Title or Position | MD
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Name | PURSHOTAM NAGWANI
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Credential | MD
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Telephone | 631-727-5112
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 143580
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License Number State | NY
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