Basic Information
| Provider Information | |||||||||
| NPI: | 1700960440 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROHEALTH CARE ASSOCIATES, LLP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ISLAND MEDICAL GROUP A DIVISION OF PROHEALTH CARE ASSOCIATES, LLP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1 DAKOTA DRIVE | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | LAKE SUCCESS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166226190 | ||||||||
| FaxNumber: | 5166222914 | ||||||||
| Practice Location | |||||||||
| Address1: | 4045 HEMPSTEAD TPKE | ||||||||
| Address2: | |||||||||
| City: | BETHPAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117145611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167317770 | ||||||||
| FaxNumber: | 5167317059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO, MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5166226000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROHEALTH CARE ASSOCIATES, LLP | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 33D0156362 | NY | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | A300055237 | 01 | NY | MEDICARE ID | OTHER |