Provider Demographics
NPI:1013038702
Name:ISLAND COSMETIC AND RECONSTRUCTIVE SURGERY, PLLC
Entity Type:Organization
Organization Name:ISLAND COSMETIC AND RECONSTRUCTIVE SURGERY, PLLC
Other - Org Name:ISLAND PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:POGGI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-977-9922
Mailing Address - Street 1:190 E JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-2033
Mailing Address - Country:US
Mailing Address - Phone:516-977-9922
Mailing Address - Fax:516-977-9926
Practice Address - Street 1:190 E JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-2033
Practice Address - Country:US
Practice Address - Phone:516-977-9922
Practice Address - Fax:516-977-9926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124739208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty