=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215103486
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOMIDIL MEDICAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2008
-----------------------------------------------------
Last Update Date | 05/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 TWIN PONDS LN
-----------------------------------------------------
City | SYOSSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11791-1004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-634-6500
-----------------------------------------------------
Fax | 845-634-9424
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 SQUADRON BLVD SUITE 400
-----------------------------------------------------
City | NEW CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10956-5214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-634-6500
-----------------------------------------------------
Fax | 845-634-9424
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR CODING/COMPLIANCE
-----------------------------------------------------
Name | MARIE FARRELL
-----------------------------------------------------
Credential | RN CCSP
-----------------------------------------------------
Telephone | 845-634-6500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 211961
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------