=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871760876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ISLAND PSYCHIATRIC SERVICES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2008
-----------------------------------------------------
Last Update Date | 05/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 87 COLD SPRING ROAD
-----------------------------------------------------
City | SYOSSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11791-3142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-385-1288
-----------------------------------------------------
Fax | 631-547-6471
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 87 COLD SPRING ROAD
-----------------------------------------------------
City | SYOSSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11791-3142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-385-1288
-----------------------------------------------------
Fax | 631-547-6471
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LARRY J SLOANE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 631-385-1288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 1537531
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------