Provider Demographics
NPI:1508066440
Name:NORTHSIDE PRIMARY MEDICAL CARE PC
Entity Type:Organization
Organization Name:NORTHSIDE PRIMARY MEDICAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WEI
Authorized Official - Middle Name:K
Authorized Official - Last Name:KAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-435-4358
Mailing Address - Street 1:3001 EXPRESSWAY DR N
Mailing Address - Street 2:SUITE 200C
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5301
Mailing Address - Country:US
Mailing Address - Phone:631-435-4358
Mailing Address - Fax:631-435-4583
Practice Address - Street 1:3001 EXPRESSWAY DR N
Practice Address - Street 2:SUITE 200C
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749-5301
Practice Address - Country:US
Practice Address - Phone:631-435-4358
Practice Address - Fax:631-435-4583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY160056207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW4T351Medicare PIN