Provider Demographics
NPI:1821319575
Name:HEALTHSOURCE MEDICAL SERVICES MEDFORD, PLLC
Entity Type:Organization
Organization Name:HEALTHSOURCE MEDICAL SERVICES MEDFORD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-435-0110
Mailing Address - Street 1:3001 EXPRESS DR N
Mailing Address - Street 2:SUITE 200C
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5301
Mailing Address - Country:US
Mailing Address - Phone:631-435-0110
Mailing Address - Fax:631-435-4583
Practice Address - Street 1:1743 N OCEAN AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2649
Practice Address - Country:US
Practice Address - Phone:631-758-3100
Practice Address - Fax:631-758-3168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167755207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty