Provider Demographics
NPI:1821183823
Name:BEACH & SURF MEDICAL, PC
Entity Type:Organization
Organization Name:BEACH & SURF MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:KLEINER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:516-431-7600
Mailing Address - Street 1:1011 W BEECH ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-1203
Mailing Address - Country:US
Mailing Address - Phone:516-431-7600
Mailing Address - Fax:516-431-7691
Practice Address - Street 1:1011 W BEECH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-1203
Practice Address - Country:US
Practice Address - Phone:516-431-7600
Practice Address - Fax:516-431-7691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211117207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02136565Medicaid
NYWEX521Medicare PIN
NY02136565Medicaid