Provider Demographics
NPI:1669075651
Name:MEDICAL SERVICES OF KIPS BAY PC
Entity type:Organization
Organization Name:MEDICAL SERVICES OF KIPS BAY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT & CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CUSACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-321-6058
Mailing Address - Street 1:325 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3114
Mailing Address - Country:US
Mailing Address - Phone:516-358-8100
Mailing Address - Fax:631-654-1474
Practice Address - Street 1:170 GREAT NECK RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-3357
Practice Address - Country:US
Practice Address - Phone:516-487-4464
Practice Address - Fax:516-487-4980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-20
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty