=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871947895
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERNAL MEDICINE SPECIALIST OF NEW YORK P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2016
-----------------------------------------------------
Last Update Date | 04/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 COMMUNITY DR
-----------------------------------------------------
City | MANHASSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11030-3816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-562-0100
-----------------------------------------------------
Fax | 631-719-2220
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 TALLEY RD
-----------------------------------------------------
City | ROSLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11576-2530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-633-6772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | MAIRAJ UD DIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 516-633-6772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 236531
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------