Basic Information
| Provider Information | |||||||||
| NPI: | 1801982822 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH OCEAN FAMILY MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 ROOSEVELT AVE | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117763336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317326984 | ||||||||
| FaxNumber: | 6317327019 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 ROOSEVELT AVE | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317326984 | ||||||||
| FaxNumber: | 6317327019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 05/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | SANTIAGO | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6317326984 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 217808 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02162494 | 05 | NY | MEDICAID |