Provider Demographics
NPI:1437496510
Name:ISLAND MEN'S MEDICAL HEALTH PRACTICE, PC
Entity Type:Organization
Organization Name:ISLAND MEN'S MEDICAL HEALTH PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-979-4350
Mailing Address - Street 1:1551 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-2313
Mailing Address - Country:US
Mailing Address - Phone:718-979-4350
Mailing Address - Fax:718-979-4825
Practice Address - Street 1:1551 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-2313
Practice Address - Country:US
Practice Address - Phone:718-979-4350
Practice Address - Fax:718-979-4825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY097198207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematologyGroup - Single Specialty