Provider Demographics
NPI:1063669430
Name:LONG ISLAND PODIATRY PC
Entity Type:Organization
Organization Name:LONG ISLAND PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:BRODY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:631-549-3668
Mailing Address - Street 1:5 EVELYN DR
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3805
Mailing Address - Country:US
Mailing Address - Phone:631-549-3668
Mailing Address - Fax:
Practice Address - Street 1:56340 MAIN ROAD
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11725-3805
Practice Address - Country:US
Practice Address - Phone:631-765-2772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004211213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3902290001Medicare NSC
NY3902290001Medicare PIN