Provider Demographics
NPI:1689862880
Name:MITCHELL S. MEYERSON, MD, PC
Entity Type:Organization
Organization Name:MITCHELL S. MEYERSON, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MEYERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-369-3474
Mailing Address - Street 1:1015 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2735
Mailing Address - Country:US
Mailing Address - Phone:631-369-3474
Mailing Address - Fax:631-369-6265
Practice Address - Street 1:1015 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2735
Practice Address - Country:US
Practice Address - Phone:631-369-3474
Practice Address - Fax:631-369-6265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183449174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG02008Medicare UPIN