Provider Demographics
NPI:1154332344
Name:SOUTH NASSAU ORTHOPEDIC SURGERY AND SPORTS MEDICINE, P.C.
Entity Type:Organization
Organization Name:SOUTH NASSAU ORTHOPEDIC SURGERY AND SPORTS MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-825-1101
Mailing Address - Street 1:64 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-5407
Mailing Address - Country:US
Mailing Address - Phone:516-825-1101
Mailing Address - Fax:516-568-2840
Practice Address - Street 1:64 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-5407
Practice Address - Country:US
Practice Address - Phone:516-825-1101
Practice Address - Fax:516-568-2840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131901174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEN391Medicare ID - Type Unspecified