Provider Demographics
NPI:1306841911
Name:SOUTH ISLAND MEDICAL CARE PC
Entity Type:Organization
Organization Name:SOUTH ISLAND MEDICAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ SOLO PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:M HANI
Authorized Official - Middle Name:
Authorized Official - Last Name:SALAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-447-8860
Mailing Address - Street 1:76 SOUTHAVEN AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3745
Mailing Address - Country:US
Mailing Address - Phone:631-447-8860
Mailing Address - Fax:631-447-8862
Practice Address - Street 1:76 SOUTHAVEN AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-3745
Practice Address - Country:US
Practice Address - Phone:631-447-8860
Practice Address - Fax:631-447-8862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207811207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5081A1OtherEMPIRE BC/BS
NY9569338OtherCIGNA
NY01770227Medicaid
NY640938OtherHEALTHCARE PARTNERS IPA
NY7082351OtherAETNA
NYP2666424OtherOXFORD
NY115904OtherVYTRA
NY5081A1OtherEMPIRE BC/BS
NYWHA211Medicare ID - Type Unspecified