=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972771004
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PORT JEFFERSON EKG ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2008
-----------------------------------------------------
Last Update Date | 05/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | JOHN T. MATHER MEMORIAL HOSPITAL 75 NORTH COUNTRY ROAD
-----------------------------------------------------
City | PORT JEFFERSON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-642-0183
-----------------------------------------------------
Fax | 631-642-0183
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 977
-----------------------------------------------------
City | PORT JEFFERSON STATION
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11776-0830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-642-0183
-----------------------------------------------------
Fax | 631-642-0183
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | VIRGINIA ROMANO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 631-642-0183
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 120676
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------