=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871922898
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ISLAND CONCIERGE MEDICAL SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2013
-----------------------------------------------------
Last Update Date | 12/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3400 NESCONSET HWY. SUITE 103
-----------------------------------------------------
City | EAST SETAUKET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-675-9393
-----------------------------------------------------
Fax | 631-675-9391
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3400 NESCONSET HWY. SUITE 103
-----------------------------------------------------
City | EAST SETAUKET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-675-9393
-----------------------------------------------------
Fax | 631-675-9391
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DOCTOR
-----------------------------------------------------
Name | MOHAMED SAMEEN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 631-675-9393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 214732
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------