Provider Demographics
NPI:1174892798
Name:LONG ISLAND NEUROLOGICAL, PC
Entity type:Organization
Organization Name:LONG ISLAND NEUROLOGICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:MACIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-240-7848
Mailing Address - Street 1:10119 39TH AVE
Mailing Address - Street 2:SUITE # 101
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-4806
Mailing Address - Country:US
Mailing Address - Phone:347-808-8324
Mailing Address - Fax:347-808-8326
Practice Address - Street 1:10119 39TH AVE
Practice Address - Street 2:SUITE # 101
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-4806
Practice Address - Country:US
Practice Address - Phone:347-808-8324
Practice Address - Fax:347-808-8326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025085225100000X
NY2209932084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY220993OtherLICENSE NUMBER