Provider Demographics
NPI:1467666461
Name:SOUTHAMPTON MEDICAL PC
Entity Type:Organization
Organization Name:SOUTHAMPTON MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MD
Authorized Official - Prefix:DR
Authorized Official - First Name:SHOBHA
Authorized Official - Middle Name:R
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-283-4048
Mailing Address - Street 1:425 COUNTY ROAD 39A
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-5277
Mailing Address - Country:US
Mailing Address - Phone:631-283-4048
Mailing Address - Fax:631-283-5396
Practice Address - Street 1:425 COUNTY ROAD 39A
Practice Address - Street 2:SUITE 201
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5277
Practice Address - Country:US
Practice Address - Phone:631-283-4048
Practice Address - Fax:631-283-5396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203693174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01837663Medicaid
NY21N631Medicare PIN
NYG45788Medicare UPIN
NYWGC601Medicare PIN