Provider Demographics
NPI:1639208200
Name:ISLAND SOUTH CHIROPRACTIC PC
Entity Type:Organization
Organization Name:ISLAND SOUTH CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERGIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:718-966-7000
Mailing Address - Street 1:91 FOSTER RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309
Mailing Address - Country:US
Mailing Address - Phone:718-966-7000
Mailing Address - Fax:718-317-7452
Practice Address - Street 1:91 FOSTER RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309
Practice Address - Country:US
Practice Address - Phone:718-966-7000
Practice Address - Fax:718-317-7452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010715NY111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7929464OtherAETNA
NYP2952873OtherOXFORD
NJP2952873OtherOXFORD
NJP2952873OtherOXFORD