Provider Demographics
NPI:1235301185
Name:HAVEN MEDICAL SERVICES, PLC
Entity Type:Organization
Organization Name:HAVEN MEDICAL SERVICES, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORAZON
Authorized Official - Middle Name:M
Authorized Official - Last Name:GO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-473-3304
Mailing Address - Street 1:1350 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3078
Mailing Address - Country:US
Mailing Address - Phone:631-473-3304
Mailing Address - Fax:631-474-1692
Practice Address - Street 1:1350 ROUTE 112
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3078
Practice Address - Country:US
Practice Address - Phone:631-473-3304
Practice Address - Fax:631-474-1692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115112207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00211463Medicaid
NYWES921Medicare PIN