=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558899989
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPREHENSIVE FAMILY MEDICAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2017
-----------------------------------------------------
Last Update Date | 12/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 488 E JERICHO TPKE
-----------------------------------------------------
City | HUNTINGTON STATION
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11746-7328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-470-2572
-----------------------------------------------------
Fax | 631-759-2921
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 488 E JERICHO TPKE
-----------------------------------------------------
City | HUNTINGTON STATION
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11746-7328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-470-2572
-----------------------------------------------------
Fax | 631-759-2921
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | DEREK MERCER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-841-7318
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 238105-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------