Provider Demographics
NPI:1568451243
Name:MASSAPEQUA GASTROENTEROLOGY ASSOC LLC
Entity Type:Organization
Organization Name:MASSAPEQUA GASTROENTEROLOGY ASSOC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HERRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-796-9000
Mailing Address - Street 1:850 HICKSVILLE RD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783
Mailing Address - Country:US
Mailing Address - Phone:516-796-9000
Mailing Address - Fax:516-796-6360
Practice Address - Street 1:850 HICKSVILLE RD
Practice Address - Street 2:SUITE #100
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783
Practice Address - Country:US
Practice Address - Phone:516-796-9000
Practice Address - Fax:516-796-6360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W0N071Medicare ID - Type Unspecified