Provider Demographics
NPI:1659655157
Name:SHOREHAM MEDICAL SERVICES PC
Entity Type:Organization
Organization Name:SHOREHAM MEDICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SHAREHOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:YEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-744-3303
Mailing Address - Street 1:45 ROUTE 25A
Mailing Address - Street 2:
Mailing Address - City:SHOREHAM
Mailing Address - State:NY
Mailing Address - Zip Code:11786-1389
Mailing Address - Country:US
Mailing Address - Phone:631-744-3303
Mailing Address - Fax:631-744-1627
Practice Address - Street 1:45 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:SHOREHAM
Practice Address - State:NY
Practice Address - Zip Code:11786-1389
Practice Address - Country:US
Practice Address - Phone:631-744-3303
Practice Address - Fax:631-744-1627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty