Provider Demographics
NPI:1225201262
Name:PROTHERA MEDICAL
Entity Type:Organization
Organization Name:PROTHERA MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:PAPPAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-424-1240
Mailing Address - Street 1:1274 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1274 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901
Practice Address - Country:US
Practice Address - Phone:631-424-1240
Practice Address - Fax:631-424-1241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222059208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty