Basic Information
Provider Information | |||||||||
NPI: | 1689205692 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTH SHORE HEMATOLOGY/ONCOLOGY ASSOCIATES PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NY CANCER & BLOOD SPECIALISTS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1500 ROUTE 112 BLDG 4 | ||||||||
Address2: |   | ||||||||
City: | PORT JEFFERSON STATION | ||||||||
State: | NY | ||||||||
PostalCode: | 117768055 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6317513000 | ||||||||
FaxNumber: | 6315096559 | ||||||||
Practice Location | |||||||||
Address1: | 640 COUNTY ROAD 39 | ||||||||
Address2: |   | ||||||||
City: | SOUTHAMPTON | ||||||||
State: | NY | ||||||||
PostalCode: | 119685219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6317513000 | ||||||||
FaxNumber: | 6315096559 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/29/2020 | ||||||||
LastUpdateDate: | 01/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DANDRAIA | ||||||||
AuthorizedOfficialFirstName: | PATRICIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
AuthorizedOfficialTelephone: | 6317513000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QR0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
ID | Type | State | Issuer | Description | 03005369 | 05 | NY |   | MEDICAID |