Provider Demographics
NPI:1629256342
Name:WANTAGH INTERNAL MEDICINE, PC
Entity Type:Organization
Organization Name:WANTAGH INTERNAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:R
Authorized Official - Last Name:BARTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-785-1200
Mailing Address - Street 1:2155 WANTAGH AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-3915
Mailing Address - Country:US
Mailing Address - Phone:516-785-1200
Mailing Address - Fax:516-785-8969
Practice Address - Street 1:2155 WANTAGH AVE
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-3915
Practice Address - Country:US
Practice Address - Phone:516-785-1200
Practice Address - Fax:516-785-8969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1398351172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB79330Medicare UPIN
NYW09811Medicare PIN