MEDICARE: OEDMG MEDICAL PC

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1578728424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OEDMG MEDICAL PC

Provider Business Mailing Address
First Line	:	201 PORTION RD STE B
Second Line	:
City	:	RONKONKOMA
State	:	NY
Zip	:	11779-4172
Country	:	US
Telephone Number	:	516-872-7001
Fax Number	:	516-872-7015

Provider Business Practice Location Address
First Line	:	201 PORTION RD STE B
Second Line	:
City	:	RONKONKOMA
State	:	NY
Zip	:	11779-4172
Country	:	US
Telephone Number	:	516-872-7001
Fax Number	:	516-872-7015

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DANIEL ROBERT LANDOLPHI
Credential	:	MD
Telephone Number	:	516-872-7001

Provider Enumeration Date	:	07/21/2008
Last Update Date	:	11/07/2008

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Directions to “OEDMG MEDICAL PC ” Practice Location

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