Provider Demographics
NPI:1780855817
Name:AMITYVILLE INTERNAL MEDICINE, P.C.
Entity Type:Organization
Organization Name:AMITYVILLE INTERNAL MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:QUENZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-264-0924
Mailing Address - Street 1:49 IRELAND PL
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2902
Mailing Address - Country:US
Mailing Address - Phone:631-264-0924
Mailing Address - Fax:631-264-3503
Practice Address - Street 1:49 IRELAND PL
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2902
Practice Address - Country:US
Practice Address - Phone:631-264-0924
Practice Address - Fax:631-264-3503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY132857207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00447296Medicaid
NYWJ6411OtherMEDICARE ID
NYC07549Medicare UPIN