Provider Demographics
NPI:1275619694
Name:ATTIVISSIMO, LORI ANN (MD, FACP)
Entity Type:Individual
Prefix:
First Name:LORI ANN
Middle Name:
Last Name:ATTIVISSIMO
Suffix:
Gender:F
Credentials:MD, FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 CHESTNUT LN
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-1918
Mailing Address - Country:US
Mailing Address - Phone:516-353-4790
Mailing Address - Fax:
Practice Address - Street 1:99 SUNNYSIDE BLVD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2901
Practice Address - Country:US
Practice Address - Phone:516-832-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186961207RH0003X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01635712Medicaid
NYG-22722Medicare UPIN
NY01635712Medicaid