Provider Demographics
NPI:1295788966
Name:LONG ISLAND PROFESSIONAL MEDICAL SERVICES PC
Entity type:Organization
Organization Name:LONG ISLAND PROFESSIONAL MEDICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:FORTUNATO
Authorized Official - Last Name:SPADAFORA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:516-877-1518
Mailing Address - Street 1:901 STEWART AVE
Mailing Address - Street 2:STE 275
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530
Mailing Address - Country:US
Mailing Address - Phone:516-877-1518
Mailing Address - Fax:516-877-1561
Practice Address - Street 1:901 STEWART AVE
Practice Address - Street 2:STE 275
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530
Practice Address - Country:US
Practice Address - Phone:516-877-1518
Practice Address - Fax:516-877-1561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1878871207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F85168Medicare UPIN
W7P491Medicare ID - Type Unspecified