Basic Information
Provider Information | |||||||||
NPI: | 1881652923 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANN | ||||||||
FirstName: | NEEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1500 ROUTE 112 BLDG 4 | ||||||||
Address2: | SUITE101 | ||||||||
City: | PORT JEFFERSON STATION | ||||||||
State: | NY | ||||||||
PostalCode: | 11776 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6317513000 | ||||||||
FaxNumber: | 6315096559 | ||||||||
Practice Location | |||||||||
Address1: | 333 BROADWAY | ||||||||
Address2: |   | ||||||||
City: | AMITYVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 117012719 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6317892020 | ||||||||
FaxNumber: | 6317895669 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2006 | ||||||||
LastUpdateDate: | 08/06/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 241885 | NY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 000000129615 | 01 | NY | GHI HMO | OTHER | 0378572 | 01 | NY | GHI PPO | OTHER |