Provider Demographics
NPI:1821566969
Name:210 MINEOLA MEDICAL PC
Entity Type:Organization
Organization Name:210 MINEOLA MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:IRENA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSHEEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-612-9837
Mailing Address - Street 1:211 BROADWAY STE 205
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3290
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4218
Practice Address - Country:US
Practice Address - Phone:516-279-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty