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General NPI Number Information
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NPI Number | 1821566969
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Entity Type | Organization
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Legal Business Name | 210 MINEOLA MEDICAL PC
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Dates
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Enumeration Date | 11/07/2018
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Last Update Date | 11/07/2018
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Provider Practice Location Address
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Address Line | 210 OLD COUNTRY RD
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City | MINEOLA
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State | NY
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Zip | 11501-4218
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Country | US
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Telephone | 516-279-4400
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Fax |
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Provider Business Mailing Address
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Address Line | 211 BROADWAY STE 205
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City | LYNBROOK
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State | NY
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Zip | 11563-3290
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING COORDINATOR
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Name | IRENA MUSHEEV
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Credential |
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Telephone | 516-612-9837
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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 |
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License Number State |
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