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General NPI Number Information
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NPI Number | 1942631270
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Entity Type | Organization
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Legal Business Name | GREAT NECK MEDICINE PC
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Dates
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Enumeration Date | 12/12/2013
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Last Update Date | 12/12/2013
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Provider Practice Location Address
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Address Line | 290 COMMUNITY DR
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City | GREAT NECK
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State | NY
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Zip | 11021-5504
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Country | US
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Telephone | 516-487-1902
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Fax | 516-487-4156
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Provider Business Mailing Address
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Address Line | 290 COMMUNITY DR
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City | GREAT NECK
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State | NY
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Zip | 11021-5504
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | RUSSELL SURASKY
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Credential | DO
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Telephone | 516-487-1902
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 260969
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License Number State | NY
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