Provider Demographics
NPI:1689205692
Name:NORTH SHORE HEMATOLOGY/ONCOLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:NORTH SHORE HEMATOLOGY/ONCOLOGY ASSOCIATES PC
Other - Org Name:NY CANCER & BLOOD SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DANDRAIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-751-3000
Mailing Address - Street 1:1500 ROUTE 112 BLDG 4
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8055
Mailing Address - Country:US
Mailing Address - Phone:631-751-3000
Mailing Address - Fax:631-509-6559
Practice Address - Street 1:640 COUNTY ROAD 39
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5219
Practice Address - Country:US
Practice Address - Phone:631-751-3000
Practice Address - Fax:631-509-6559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03005369Medicaid