Provider Demographics
NPI:1376828426
Name:LONG ISLAND FERTILITY, PLLC
Entity Type:Organization
Organization Name:LONG ISLAND FERTILITY, PLLC
Other - Org Name:LONG ISLAND IVF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAVECH
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:860-678-3428
Mailing Address - Street 1:8 CORPORATE CENTER DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-3193
Mailing Address - Country:US
Mailing Address - Phone:631-752-0606
Mailing Address - Fax:631-331-1332
Practice Address - Street 1:8 CORPORATE CENTER DR
Practice Address - Street 2:SUITE 101
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3193
Practice Address - Country:US
Practice Address - Phone:631-752-0606
Practice Address - Fax:631-331-1332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY33D1081165OtherCLIA