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General NPI Number Information
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NPI Number | 1710126271
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Entity Type | Organization
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Legal Business Name | SURGICAL GROUP PROF CORP
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Dates
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Enumeration Date | 02/06/2009
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Last Update Date | 02/06/2009
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Provider Practice Location Address
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Address Line | 157 BROADWAY
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City | AMITYVILLE
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State | NY
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Zip | 11701-2729
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Country | US
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Telephone | 631-598-7757
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Fax | 631-598-7759
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Provider Business Mailing Address
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Address Line | 157 BROADWAY
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City | AMITYVILLE
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State | NY
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Zip | 11701-2729
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Country | US
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Telephone | 631-598-7757
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Fax | 631-598-7759
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Authorized Official
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Title or Position | PRESIDENT
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Name | JEFFREY K NUSSBAUM
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Credential | M.D.
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Telephone | 631-598-7757
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | 147879
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 147879
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License Number State | NY
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