Provider Demographics
NPI:1043492374
Name:N. S. SO ISLAND DIAG GRP
Entity Type:Organization
Organization Name:N. S. SO ISLAND DIAG GRP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MRS
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BUHRTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-210-0132
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-0549
Mailing Address - Country:US
Mailing Address - Phone:718-471-5400
Mailing Address - Fax:718-382-5400
Practice Address - Street 1:9009 ROCKAWAY BCH BLVD
Practice Address - Street 2:
Practice Address - City:ROCKAWAY BEACH
Practice Address - State:NY
Practice Address - Zip Code:11693-1531
Practice Address - Country:US
Practice Address - Phone:718-474-9631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH ISLAND MEDICAL ASSOCIATES P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-28
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33D0875629291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG560950OtherOXFORD
NY000142305OtherAMERICHOICE
NY113493693OtherAFFINITY
NY000142305OtherAMERICHOICE
NY113493693OtherAFFINITY
NY=========P01OtherHEALTHFIRST
NY=========Medicare PIN
NY02076Medicare PIN