MEDICARE: LAKE SUCCESS WOMEN'S MEDICAL CARE

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	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1851571251
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE SUCCESS WOMEN'S MEDICAL CARE

Provider Business Mailing Address
First Line	:	1999 MARCUS AVE
Second Line	:	SUITE 108
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11042-1017
Country	:	US
Telephone Number	:	516-466-3663
Fax Number	:	516-773-3201

Provider Business Practice Location Address
First Line	:	1999 MARCUS AVE
Second Line	:	SUITE 108
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11042-1017
Country	:	US
Telephone Number	:	516-466-3663
Fax Number	:	516-773-3201

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	ROBERT A JASON
Credential	:	M.D.
Telephone Number	:	516-466-3663

Provider Enumeration Date	:	11/14/2007
Last Update Date	:	06/29/2009

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