=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922603075
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONG ISLAND LUNG SURGERY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2020
-----------------------------------------------------
Last Update Date | 10/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 37 NORTHERN BLVD UNIT 15
-----------------------------------------------------
City | GREENVALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11548-4001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-715-3192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 CHARLES WAY
-----------------------------------------------------
City | GLEN HEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11545-2736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MARK H GENOVESI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 917-715-3192
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------