Provider Demographics
NPI: | 1346768702 |
---|---|
Name: | SMITHTOWN INTEGRATED HEALTH LLC |
Entity Type: | Organization |
Organization Name: | SMITHTOWN INTEGRATED HEALTH LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PHYSICIAN |
Authorized Official - Prefix: | |
Authorized Official - First Name: | STEPHANIE |
Authorized Official - Middle Name: | J |
Authorized Official - Last Name: | WALLMAN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DO |
Authorized Official - Phone: | 631-265-1763 |
Mailing Address - Street 1: | 32 LAWRENCE AVE STE 206 |
Mailing Address - Street 2: | |
Mailing Address - City: | SMITHTOWN |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 11787-3605 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 32 LAWRENCE AVE STE 206 |
Practice Address - Street 2: | |
Practice Address - City: | SMITHTOWN |
Practice Address - State: | NY |
Practice Address - Zip Code: | 11787-3605 |
Practice Address - Country: | US |
Practice Address - Phone: | 631-265-1763 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-09-06 |
Last Update Date: | 2018-04-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 288963 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Single Specialty |