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General NPI Number Information
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NPI Number | 1396925947
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Entity Type | Organization
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Legal Business Name | MI MEDICAL PLLC
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Dates
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Enumeration Date | 11/13/2007
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Last Update Date | 11/13/2007
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Provider Practice Location Address
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Address Line | 3279 VETERANS MEMORIAL HWY STE 5
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City | RONKONKOMA
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State | NY
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Zip | 11779-7673
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Country | US
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Telephone | 631-737-4949
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Fax |
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Provider Business Mailing Address
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Address Line | 3279 VETERANS MEMORIAL HWY STE 5
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City | RONKONKOMA
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State | NY
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Zip | 11779-7673
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Country | US
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Telephone | 631-737-4949
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MYLES IVAN ROSENTHAL
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Credential | M.D.
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Telephone | 631-737-4949
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 154360
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License Number State | NY
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