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General NPI Number Information
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NPI Number | 1417024001
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Entity Type | Organization
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Legal Business Name | PORT NEUROLOGY PC
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Dates
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Enumeration Date | 11/29/2006
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Last Update Date | 01/19/2011
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Provider Practice Location Address
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Address Line | 640 BELLE TERRE RD BUILDING H
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-1936
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Country | US
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Telephone | 631-331-8774
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Fax | 631-331-8775
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Provider Business Mailing Address
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Address Line | 640 BELLE TERRE RD BUILDING H
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-1936
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Country | US
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Telephone | 631-331-8774
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Fax | 631-331-8775
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. AJAY V BERDIA
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Credential | M.D.
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Telephone | 631-331-8774
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 196859
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License Number State | NY
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