Provider Demographics
NPI:1952674897
Name:MYLENE COLUCCI MD PC
Entity Type:Organization
Organization Name:MYLENE COLUCCI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MYLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-676-2878
Mailing Address - Street 1:3 SCHOOL ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2590
Mailing Address - Country:US
Mailing Address - Phone:516-676-2878
Mailing Address - Fax:516-674-2256
Practice Address - Street 1:3 SCHOOL ST
Practice Address - Street 2:SUITE 303
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2590
Practice Address - Country:US
Practice Address - Phone:516-676-2878
Practice Address - Fax:516-674-2256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226904207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY226904OtherLICENSE