Provider Demographics
NPI:1467134684
Name:1717 MEDICAL PC
Entity Type:Organization
Organization Name:1717 MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-482-2754
Mailing Address - Street 1:1717 VETERANS MEMORIAL HWY STE 1
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-1532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 VETERANS MEMORIAL HWY STE 1
Practice Address - Street 2:
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749-1532
Practice Address - Country:US
Practice Address - Phone:631-203-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty