MEDICARE: GREAT SOUTH BAY FAMILY MEDICAL PRACTICE LLP

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1588824981
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT SOUTH BAY FAMILY MEDICAL PRACTICE LLP

Provider Business Mailing Address
First Line	:	213 MONTAUK HWY
Second Line	:
City	:	WEST SAYVILLE
State	:	NY
Zip	:	11796-1800
Country	:	US
Telephone Number	:	631-563-6205
Fax Number	:	631-563-7718

Provider Business Practice Location Address
First Line	:	213 MONTAUK HWY
Second Line	:
City	:	WEST SAYVILLE
State	:	NY
Zip	:	11796-1800
Country	:	US
Telephone Number	:	631-563-6205
Fax Number	:	631-563-7718

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MR. JULIE WESTBAY
Credential	:
Telephone Number	:	631-563-6205

Provider Enumeration Date	:	06/10/2008
Last Update Date	:	12/01/2011

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