Provider Demographics
NPI:1811186083
Name:MID-SUFFOLK MEDICAL CARE PC
Entity Type:Organization
Organization Name:MID-SUFFOLK MEDICAL CARE PC
Other - Org Name:ISLAND MEDICAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:R
Authorized Official - Last Name:AZAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-462-6644
Mailing Address - Street 1:6277 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-2837
Mailing Address - Country:US
Mailing Address - Phone:631-462-6644
Mailing Address - Fax:631-462-9890
Practice Address - Street 1:6277 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2837
Practice Address - Country:US
Practice Address - Phone:631-462-6644
Practice Address - Fax:631-462-9890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220310173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02131226Medicaid
NY02131226Medicaid