=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871175141
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOWN AND COUNTRY MEDICAL GROUP PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2021
-----------------------------------------------------
Last Update Date | 04/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 GRACE AVE
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021-2415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-693-7362
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 WEBSTER AVE
-----------------------------------------------------
City | MANHASSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11030-1965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-719-3069
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO, MANAGING PARTNER
-----------------------------------------------------
Name | DR. RICHARD ANTHONY MARINO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 855-698-7362
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------