Provider Demographics
NPI:1639221039
Name:LONG ISLAND CARDIOVASCULAR MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:LONG ISLAND CARDIOVASCULAR MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZATION DEPARTMENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-422-1900
Mailing Address - Street 1:200 W. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702
Mailing Address - Country:US
Mailing Address - Phone:631-422-1900
Mailing Address - Fax:631-422-2600
Practice Address - Street 1:200 W. MAIN STREET
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702
Practice Address - Country:US
Practice Address - Phone:631-422-1900
Practice Address - Fax:631-422-2600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140169174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW-2253-1Medicare ID - Type Unspecified