Provider Demographics
NPI:1508045279
Name:SOUTH NASSAU INTERNAL MEDICINE ASSOCIATES, LLP
Entity Type:Organization
Organization Name:SOUTH NASSAU INTERNAL MEDICINE ASSOCIATES, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-379-3139
Mailing Address - Street 1:155 W MERRICK RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-3743
Mailing Address - Country:US
Mailing Address - Phone:516-379-3139
Mailing Address - Fax:516-868-0683
Practice Address - Street 1:155 W MERRICK RD
Practice Address - Street 2:SUITE 101
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3743
Practice Address - Country:US
Practice Address - Phone:516-379-3139
Practice Address - Fax:516-868-0683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164466207R00000X
NYF46077207R00000X
NY149408207RC0000X
NY112891207RE0101X
NY0107171363A00000X
NYF3019041363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW03621Medicare PIN