=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417239500
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH SHORE HAMPTON MEDICAL AND SURGICAL EYE CARE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2011
-----------------------------------------------------
Last Update Date | 09/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 54 COMMERCE AVE SUITE 6 RIVERHEAD COMMERCE PARK
-----------------------------------------------------
City | RIVERHEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11901-4454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-265-8780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 260 MIDDLE COUNTRY RD 201
-----------------------------------------------------
City | SMITHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11787-2982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | SHAUN ANDERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 631-265-8780
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------