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General NPI Number Information
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NPI Number | 1225748494
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Entity Type | Organization
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Legal Business Name | 25A MEDICAL
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Dates
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Enumeration Date | 11/29/2022
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Last Update Date | 11/29/2022
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Provider Practice Location Address
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Address Line | 100 W SUFFOLK AVENUE UNIT G
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City | CENTRAL ISLIP
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State | NY
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Zip | 11722-2430
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Country | US
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Telephone | 631-993-5400
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Fax | 518-712-1634
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Provider Business Mailing Address
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Address Line | 100 W SUFFOLK AVENUE UNIT G
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City | CENTRAL ISLIP
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State | NY
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Zip | 11722-2430
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Country | US
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Telephone | 631-993-5400
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Fax | 518-712-1634
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Authorized Official
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Title or Position | OWNER
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Name | ANTHONY THEODORIS
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Credential |
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Telephone | 631-993-5400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number |
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License Number State |
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