Provider Demographics
NPI:1386181840
Name:IMAM MEDICAL PC
Entity Type:Organization
Organization Name:IMAM MEDICAL PC
Other - Org Name:THE CIIT CENTER OF CENTER MORICHES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEITZBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-243-8660
Mailing Address - Street 1:131 SUNNYSIDE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-1539
Mailing Address - Country:US
Mailing Address - Phone:516-243-8660
Mailing Address - Fax:
Practice Address - Street 1:2 UNION AVE
Practice Address - Street 2:
Practice Address - City:CENTER MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11934-3324
Practice Address - Country:US
Practice Address - Phone:631-645-3613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-23
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY159557-1207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1144394826Medicaid
NY8300158279Medicare PIN
NY1366624918Medicare PIN
NY1922094366Medicare PIN