MEDICARE: LONG ISLAND PRIMARY MEDICAL CARE/DBA VILLAGE PEDIATRICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician		NY

General Provider Information

NPI Number	:	1316992886
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONG ISLAND PRIMARY MEDICAL CARE/DBA VILLAGE PEDIATRICS

Provider Business Mailing Address
First Line	:	975 FRANKLIN AVENUE,SUITE 101
Second Line	:	SUITE 101
City	:	GARDEN CITY
State	:	NY
Zip	:	11783
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	975 FRANKLIN AVE
Second Line	:	SUITE 101
City	:	GARDEN CITY
State	:	NY
Zip	:	11530-2911
Country	:	US
Telephone Number	:	516-248-8334
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	JEFFREY W. LIEBERMAN
Credential	:	MD
Telephone Number	:	516-248-8334

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	08/22/2020

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