Provider Demographics
NPI:1083492128
Name:LAKE SUCCESS HEALTH MEDICAL WELLNESS PC
Entity Type:Organization
Organization Name:LAKE SUCCESS HEALTH MEDICAL WELLNESS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:914-860-5578
Mailing Address - Street 1:295 MADISON AVE RM 407
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-6438
Mailing Address - Country:US
Mailing Address - Phone:914-960-5578
Mailing Address - Fax:
Practice Address - Street 1:2001 MARCUS AVE STE W95
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-2052
Practice Address - Country:US
Practice Address - Phone:917-524-7246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-19
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty