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General NPI Number Information
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NPI Number | 1972256691
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Entity Type | Organization
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Legal Business Name | STATE STREET MEDICAL PLLC
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Dates
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Enumeration Date | 02/02/2022
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Last Update Date | 12/08/2022
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Provider Practice Location Address
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Address Line | 555 N COUNTRY RD
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City | SAINT JAMES
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State | NY
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Zip | 11780-1444
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Country | US
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Telephone | 631-862-1737
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Fax |
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Provider Business Mailing Address
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Address Line | 85 S OCEAN AVE
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City | PATCHOGUE
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State | NY
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Zip | 11772-3702
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Country | US
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Telephone | 516-851-6087
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | STEPHEN LITVAK
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Credential |
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Telephone | 516-851-6087
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number |
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License Number State |
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