Provider Demographics
NPI:1851690788
Name:LONG ISLAND WOMEN'S OBSTETRICS AND GYNECOLOGY PLLC
Entity Type:Organization
Organization Name:LONG ISLAND WOMEN'S OBSTETRICS AND GYNECOLOGY PLLC
Other - Org Name:LONG ISLAND WOMEN'S OBS/GYN
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSCIAN/OWNER SOLO LLC PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:R
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-488-8145
Mailing Address - Street 1:3003 NEW HYDE PARK RD
Mailing Address - Street 2:SUITE 407
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1206
Mailing Address - Country:US
Mailing Address - Phone:516-488-8145
Mailing Address - Fax:516-488-6722
Practice Address - Street 1:3003 NEW HYDE PARK RD
Practice Address - Street 2:SUITE 407
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1206
Practice Address - Country:US
Practice Address - Phone:516-488-8145
Practice Address - Fax:516-488-6722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161044261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06E271Medicare PIN