Provider Demographics
NPI:1437255353
Name:LONG ISLAND PODIATRY GROUP, P.C.
Entity Type:Organization
Organization Name:LONG ISLAND PODIATRY GROUP, P.C.
Other - Org Name:CENTRAL PODIATRY ASSOC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPRIOLI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:516-568-2319
Mailing Address - Street 1:375 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-1134
Mailing Address - Country:US
Mailing Address - Phone:516-825-4070
Mailing Address - Fax:516-568-2318
Practice Address - Street 1:375 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-1134
Practice Address - Country:US
Practice Address - Phone:516-825-4070
Practice Address - Fax:516-825-1508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003712213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0735570001Medicare NSC
NYP2W112Medicare PIN
NYP2W111Medicare PIN