Provider Demographics
NPI:1417024001
Name:PORT NEUROLOGY PC
Entity Type:Organization
Organization Name:PORT NEUROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AJAY
Authorized Official - Middle Name:V
Authorized Official - Last Name:BERDIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-331-8774
Mailing Address - Street 1:640 BELLE TERRE RD
Mailing Address - Street 2:BUILDING H
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1936
Mailing Address - Country:US
Mailing Address - Phone:631-331-8774
Mailing Address - Fax:631-331-8775
Practice Address - Street 1:640 BELLE TERRE RD
Practice Address - Street 2:BUILDING H
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1936
Practice Address - Country:US
Practice Address - Phone:631-331-8774
Practice Address - Fax:631-331-8775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196859174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty