Provider Demographics
NPI:1437236353
Name:ISLAND ORTHOPAEDICS & SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:ISLAND ORTHOPAEDICS & SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:NIZICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-798-0111
Mailing Address - Street 1:660 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2312
Mailing Address - Country:US
Mailing Address - Phone:516-798-0111
Mailing Address - Fax:516-798-3631
Practice Address - Street 1:660 BROADWAY
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-2312
Practice Address - Country:US
Practice Address - Phone:516-798-0111
Practice Address - Fax:516-798-3631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW34961Medicare UPIN
5434920001Medicare NSC