Provider Demographics
NPI:1083966170
Name:NORTH SHORE MEDICAL PLLC
Entity Type:Organization
Organization Name:NORTH SHORE MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BASE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-806-1434
Mailing Address - Street 1:65-11 BOOTH STREET
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374
Mailing Address - Country:US
Mailing Address - Phone:718-806-1434
Mailing Address - Fax:718-806-1435
Practice Address - Street 1:21008 NORTHERN BLVD
Practice Address - Street 2:SUIT 1A
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3211
Practice Address - Country:US
Practice Address - Phone:718-281-0833
Practice Address - Fax:718-281-0566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-12
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY187770207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty