Provider Demographics
NPI:1710104641
Name:ISLAND SPINE & SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:ISLAND SPINE & SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:OBEDIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-933-4351
Mailing Address - Street 1:81 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-2920
Mailing Address - Country:US
Mailing Address - Phone:516-933-4351
Mailing Address - Fax:516-933-4352
Practice Address - Street 1:81 N BROADWAY
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-2920
Practice Address - Country:US
Practice Address - Phone:516-933-4351
Practice Address - Fax:516-933-4352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty