Provider Demographics
NPI:1760598270
Name:FAMILY MEDICAL CARE OF GLEN COVE PC
Entity Type:Organization
Organization Name:FAMILY MEDICAL CARE OF GLEN COVE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:SIEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-801-1129
Mailing Address - Street 1:154 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2023
Mailing Address - Country:US
Mailing Address - Phone:516-801-1129
Mailing Address - Fax:516-759-1509
Practice Address - Street 1:154 FOREST AVE
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2023
Practice Address - Country:US
Practice Address - Phone:516-801-1129
Practice Address - Fax:516-759-1509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176195173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01140147Medicaid
NY01140147Medicaid