Provider Demographics
NPI:1043570286
Name:SOUTH NASSAU OBSTETRICS & GYNECOLOGY, PC
Entity Type:Organization
Organization Name:SOUTH NASSAU OBSTETRICS & GYNECOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-632-3965
Mailing Address - Street 1:1 HEALTHY WAY
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-1551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-5443
Practice Address - Country:US
Practice Address - Phone:516-632-3350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH NASSAU COMMUNITIES HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-22
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100072264Medicare PIN