Provider Demographics
NPI:1851367304
Name:EAST END GERIATRIC & ADULT MEDICINE PLLC
Entity Type:Organization
Organization Name:EAST END GERIATRIC & ADULT MEDICINE PLLC
Other - Org Name:PROFESSIONAL LIMITED LIABILITY CORP.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:P
Authorized Official - Last Name:SLOTKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-765-1414
Mailing Address - Street 1:PO BOX 1437
Mailing Address - Street 2:
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971-0938
Mailing Address - Country:US
Mailing Address - Phone:631-765-1414
Mailing Address - Fax:631-765-1428
Practice Address - Street 1:50 ACKERLY POND LANE
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971-3005
Practice Address - Country:US
Practice Address - Phone:631-765-1414
Practice Address - Fax:631-765-1428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RG0300X, 363L00000X
NY23013867363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYDD8034OtherRAIL ROAD MEDICARE
NY02632497Medicaid
NY02632497Medicaid