Provider Demographics
NPI:1821284902
Name:GASTROENTEROLGY OF EASTERN LONG ISLAND LLC
Entity Type:Organization
Organization Name:GASTROENTEROLGY OF EASTERN LONG ISLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:K
Authorized Official - Last Name:GEORGOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-283-5555
Mailing Address - Street 1:PO BOX 5004
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11969-5004
Mailing Address - Country:US
Mailing Address - Phone:631-283-5555
Mailing Address - Fax:631-283-0345
Practice Address - Street 1:325 MEETING HOUSE LN
Practice Address - Street 2:BLDG 2
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5087
Practice Address - Country:US
Practice Address - Phone:631-283-5555
Practice Address - Fax:631-283-0345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194726207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW38081Medicare PIN