Physician Compare National (NPI:1194715375)

HEALTHCARE PROVIDER:

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1194715375
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	5395921472
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20110526000081
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	DEROVIRA
	Individual professional last name
Provider First Name	ALAN
	Individual professional first name
Provider Middle Name	K
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	GEORGE WASHINGTON UNIVERSITY SCHOOL OF MEDICINE
	Individual professional's medical school
Graduation Year	1984
	Individual professional's medical school graduation year
Primary Specialty	FAMILY MEDICINE
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Line 1 Street Address	30 HEMPSTEAD AVE
	Group Practice or individual's line 1 address
Line 2 Street Address	H2
	Group Practice or individual's line 2 address
City	ROCKVILLE CENTRE
	Group Practice or individual's city
State	NY
	Group Practice or individual's state
Zip Code	115704038
	Group Practice or individual's zip code (9 digits when available)
Phone Number	5167646464
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	330198
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	SOUTH NASSAU COMMUNITIES HOSPITAL
	Legal business name of hospital where individual professional provides service 1
Hospital Affiliation CCN 2	330259
	Medicare CCN of hospital where individual professional provides service 2
Hospital Affiliation LBN 2	MERCY MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 2
Hospital Affiliation CCN 3	330106
	Medicare CCN of hospital where individual professional provides service 3
Hospital Affiliation LBN 3	NS/LIJ HS-NORTH SHORE UNIVERSITY HOSPITAL AT MANHASSET
	Legal business name of hospital where individual professional provides service 3
Professional Accepts Medicare Assignment	Y