Provider Demographics
NPI:1497856256
Name:PORT JEFFERSON INTERNAL MEDICINE ASSOC
Entity Type:Organization
Organization Name:PORT JEFFERSON INTERNAL MEDICINE ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSARIO
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROMANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-331-1000
Mailing Address - Street 1:5225-15 ROUTE 347
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776
Mailing Address - Country:US
Mailing Address - Phone:631-331-1000
Mailing Address - Fax:631-928-7436
Practice Address - Street 1:5225-15 ROUTE 347
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776
Practice Address - Country:US
Practice Address - Phone:631-331-1000
Practice Address - Fax:631-928-7436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120676207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCB1781OtherRAILROAD MEDICARE
NYW11051Medicare PIN