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General NPI Number Information
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NPI Number | 1750577201
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Entity Type | Organization
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Legal Business Name | MID ISLAND INTERNAL MEDICINE, PLLC
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Dates
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Enumeration Date | 09/19/2007
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Last Update Date | 05/27/2009
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Provider Practice Location Address
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Address Line | 709 HAWKINS AVE
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City | RONKONKOMA
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State | NY
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Zip | 11779-4243
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Country | US
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Telephone | 631-588-0880
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Fax | 631-588-0391
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Provider Business Mailing Address
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Address Line | 709 HAWKINS AVE
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City | RONKONKOMA
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State | NY
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Zip | 11779-2293
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Country | US
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Telephone | 631-588-0880
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Fax | 631-588-0391
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | JENNIFER E LIOTTA
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Credential |
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Telephone | 631-588-0880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 173000000X
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Taxonomy Name | Legal Medicine
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License Number | 199922
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License Number State | NY
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