Provider Demographics
NPI:1760609572
Name:PHYSICIANS CARE OF LONG ISLAND
Entity Type:Organization
Organization Name:PHYSICIANS CARE OF LONG ISLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-935-7272
Mailing Address - Street 1:366 N BROADWAY
Mailing Address - Street 2:STE 305
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:366 N BROADWAY
Practice Address - Street 2:STE 305
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-2000
Practice Address - Country:US
Practice Address - Phone:516-935-7272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203818174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WEW601Medicare PIN