Provider Demographics
NPI:1437262755
Name:LONG ISLAND VITREO RETINAL CONSULTANTS PC
Entity Type:Organization
Organization Name:LONG ISLAND VITREO RETINAL CONSULTANTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:I
Authorized Official - Last Name:MACCARONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-466-0390
Mailing Address - Street 1:600 NORTHERN BLVD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021
Mailing Address - Country:US
Mailing Address - Phone:516-466-0390
Mailing Address - Fax:516-466-4956
Practice Address - Street 1:600 NORTHERN BLVD
Practice Address - Street 2:SUITE 216
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021
Practice Address - Country:US
Practice Address - Phone:516-466-0390
Practice Address - Fax:516-466-4956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00710554Medicaid
NYW8E001Medicare PIN
NYCF7254Medicare PIN