Provider Demographics
NPI:1700960440
Name:PROHEALTH CARE ASSOCIATES, LLP
Entity Type:Organization
Organization Name:PROHEALTH CARE ASSOCIATES, LLP
Other - Org Name:ISLAND MEDICAL GROUP A DIVISION OF PROHEALTH CARE ASSOCIATES, LLP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO, MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-622-6000
Mailing Address - Street 1:1 DAKOTA DRIVE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:LAKE SUCCESS
Mailing Address - State:NY
Mailing Address - Zip Code:11042
Mailing Address - Country:US
Mailing Address - Phone:516-622-6190
Mailing Address - Fax:516-622-2914
Practice Address - Street 1:4045 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-5611
Practice Address - Country:US
Practice Address - Phone:516-731-7770
Practice Address - Fax:516-731-7059
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROHEALTH CARE ASSOCIATES, LLP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-25
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33D0156362291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300055237OtherMEDICARE ID