Basic Information
| Provider Information | |||||||||
| NPI: | 1306043591 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH SHORE HEMATOLOGY ONCOLOGY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 235 N BELLE MEAD RD | ||||||||
| Address2: | |||||||||
| City: | EAST SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117333456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317513000 | ||||||||
| FaxNumber: | 6319412700 | ||||||||
| Practice Location | |||||||||
| Address1: | 48 ROUTE 25A | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | SMITHTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117871431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319796501 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 12/06/2007 | ||||||||
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| AuthorizedOfficialLastName: | SAMUEL | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 6317513000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | CC5178 | 01 | NY | RR MEDICARE | OTHER | 00679947 | 05 | NY | MEDICAID |