Provider Demographics
NPI:1740474402
Name:LONG ISLAND VITREO RETINAL CONSULTANTS
Entity type:Organization
Organization Name:LONG ISLAND VITREO RETINAL CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MACCARONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-466-0390
Mailing Address - Street 1:600 NORTHERN BLVD STE 216
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5200
Mailing Address - Country:US
Mailing Address - Phone:516-466-0390
Mailing Address - Fax:516-466-4956
Practice Address - Street 1:600 NORTHERN BLVD STE 216
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5200
Practice Address - Country:US
Practice Address - Phone:516-466-0390
Practice Address - Fax:516-466-4956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY44I491OtherDR E SHAKIN
NY423B91OtherDR K GRAHAM
NY5T9101OtherDR P FERRONE
NY45A371OtherDR J SHAKIN
NY316B51OtherDR V DERAMO
NY467A61OtherDR B ROSENBLATT
NY71A461OtherDR D FASTENBERG
NY5T9101OtherDR P FERRONE
NY5T9101OtherDR P FERRONE