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
StateLicense IDTaxonomies
NY288963207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty