Provider Demographics
NPI:1497940019
Name:LONG ISLAND VITREO RETINAL CONSULTANTS
Entity Type:Organization
Organization Name:LONG ISLAND VITREO RETINAL CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANNMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-466-0390
Mailing Address - Street 1:47 COMMERCE DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-3106
Mailing Address - Country:US
Mailing Address - Phone:631-905-0666
Mailing Address - Fax:516-905-0660
Practice Address - Street 1:47 COMMERCE DR
Practice Address - Street 2:SUITE 2
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-3106
Practice Address - Country:US
Practice Address - Phone:631-905-0666
Practice Address - Fax:516-905-0660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY43F372OtherDR B GOLUB
NY44I491OtherDR E SHAKIN
NY316B51OtherDR V DERAMO
NY5T9101OtherDR P FERRONE
NY71A461OtherDR FASTENBERG
NY45A371OtherDR J SHAKIN
NY423B91OtherDR K GRAHAM
NY467A61OtherDR B ROSENBLATT
NY5T9101OtherDR P FERRONE