Provider Demographics
NPI:1356455828
Name:ISLAND MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:ISLAND MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-433-3600
Mailing Address - Street 1:789 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-4907
Mailing Address - Country:US
Mailing Address - Phone:516-433-3600
Mailing Address - Fax:516-433-9490
Practice Address - Street 1:789 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4907
Practice Address - Country:US
Practice Address - Phone:516-433-3600
Practice Address - Fax:516-433-9490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Not Answered207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Not Answered207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00100918Medicaid
NY00100918Medicaid