Provider Demographics
NPI:1689813263
Name:SEAGIRT MEDICAL GROUP
Entity Type:Organization
Organization Name:SEAGIRT MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-868-8668
Mailing Address - Street 1:2004 SEAGIRT BLVD
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2802
Mailing Address - Country:US
Mailing Address - Phone:718-868-8668
Mailing Address - Fax:718-868-8611
Practice Address - Street 1:2004 SEAGIRT BLVD
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-2802
Practice Address - Country:US
Practice Address - Phone:718-868-8668
Practice Address - Fax:718-868-8611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221582207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty