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General NPI Number Information
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NPI Number | 1811031776
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Entity Type | Organization
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Legal Business Name | PATRIOT FAMILY MEDICAL ASSOCIATES PLLC
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Dates
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Enumeration Date | 02/16/2007
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Last Update Date | 06/30/2016
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Provider Practice Location Address
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Address Line | 85 ROOSEVELT AVE
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City | VALLEY STREAM
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State | NY
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Zip | 11581-1133
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Country | US
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Telephone | 516-791-9500
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Fax | 516-791-9510
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Provider Business Mailing Address
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Address Line | 85 ROOSEVELT AVE
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City | VALLEY STREAM
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State | NY
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Zip | 11581-1133
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Country | US
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Telephone | 516-791-9500
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Fax | 516-791-9510
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. LORI WILEY
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Credential |
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Telephone | 516-791-9500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 212127
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License Number State | NY
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