Provider Demographics
NPI:1255533360
Name:BRIGHTWATERS INTERNAL MEDICINE PLLC
Entity type:Organization
Organization Name:BRIGHTWATERS INTERNAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEGELHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-665-5074
Mailing Address - Street 1:200 HOWELLS RD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-5300
Mailing Address - Country:US
Mailing Address - Phone:631-665-5074
Mailing Address - Fax:631-665-1852
Practice Address - Street 1:200 HOWELLS RD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5300
Practice Address - Country:US
Practice Address - Phone:631-665-5074
Practice Address - Fax:631-665-1852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152199207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWBW621Medicare ID - Type Unspecified