Basic Information
| Provider Information | |||||||||
| NPI: | 1396794301 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MASSAPEQUA INTERNAL MEDICINE ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 HICKSVILLE RD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | SEAFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117831300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167980141 | ||||||||
| FaxNumber: | 5167980694 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 HICKSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | SEAFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117831300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167980141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 09/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | TUNISON | ||||||||
| AuthorizedOfficialFirstName: | BIANCA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5167996491 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 129708 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.