Provider Demographics
NPI:1124229562
Name:COSMETIC SURGERY OF NEW YORK PC
Entity Type:Organization
Organization Name:COSMETIC SURGERY OF NEW YORK PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-473-7070
Mailing Address - Street 1:4616 NESCONSET HWY
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2563
Mailing Address - Country:US
Mailing Address - Phone:631-473-7070
Mailing Address - Fax:631-331-2654
Practice Address - Street 1:4616 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2563
Practice Address - Country:US
Practice Address - Phone:631-473-7070
Practice Address - Fax:631-331-2654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400036602OtherPTAN
NY345041Medicare PIN
NYCO8904Medicare UPIN