Provider Demographics
NPI:1578982146
Name:HERITAGE NEW YORK MEDICAL PC
Entity Type:Organization
Organization Name:HERITAGE NEW YORK MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KATHLEEN
Authorized Official - Last Name:NIX
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:516-531-2107
Mailing Address - Street 1:501 FRANKLIN AVE
Mailing Address - Street 2:STE. 140
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-5807
Mailing Address - Country:US
Mailing Address - Phone:516-531-2001
Mailing Address - Fax:
Practice Address - Street 1:501 FRANKLIN AVE
Practice Address - Street 2:STE. 140
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-5807
Practice Address - Country:US
Practice Address - Phone:516-531-2001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-10
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
NY11-3284153364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty