Provider Demographics
NPI:1972678183
Name:FAMILY MEDICAL PRACTICE OF LONG ISLAND P.C.
Entity Type:Organization
Organization Name:FAMILY MEDICAL PRACTICE OF LONG ISLAND P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:POLOFSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-786-5692
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-0230
Mailing Address - Country:US
Mailing Address - Phone:631-786-5692
Mailing Address - Fax:631-368-4891
Practice Address - Street 1:221 BROADWAY
Practice Address - Street 2:SUITE 207
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2780
Practice Address - Country:US
Practice Address - Phone:631-786-5692
Practice Address - Fax:631-368-4891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168859207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY21003100852OtherBEECH STREET
NY2849737OtherCIGNA
NY01558938Medicaid
NY062449890OtherGREAT WEST
NY6004917OtherGHI
NY97F471OtherBLUE CROSS BLUE SHIELD
NY0490232OtherAETNA
NY080142404OtherMEDICARE RRB
NY2C8087OtherHEALTHNET
NYDA48747AOtherMDNY
NYP398100OtherOXFORD
NY0490232OtherUSHC
NY50767OtherVYTRA
NY168859OtherHIP
NY168859-A10OtherHEALTHFIRST
NY168859OtherHIP
NY21003100852OtherBEECH STREET