Provider Demographics
NPI:1932170255
Name:LONG ISLAND SURGICAL SPECIALIST, P.C.
Entity Type:Organization
Organization Name:LONG ISLAND SURGICAL SPECIALIST, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RENATO
Authorized Official - Middle Name:B
Authorized Official - Last Name:BERROYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:516-883-2212
Mailing Address - Street 1:639 PORT WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-3733
Mailing Address - Country:US
Mailing Address - Phone:516-883-2212
Mailing Address - Fax:516-767-7064
Practice Address - Street 1:639 PORT WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-3733
Practice Address - Country:US
Practice Address - Phone:516-883-2212
Practice Address - Fax:516-767-7064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2015-09-15
Deactivation Date:2006-05-31
Deactivation Code:
Reactivation Date:2007-08-02
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization