Provider Demographics
NPI:1215125760
Name:SOUTH NASSAU DERMATOLOGY
Entity type:Organization
Organization Name:SOUTH NASSAU DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCHHOLZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-766-0345
Mailing Address - Street 1:2900 HEMPSTEAD TPKE
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-1404
Mailing Address - Country:US
Mailing Address - Phone:516-520-5280
Mailing Address - Fax:516-520-5283
Practice Address - Street 1:2900 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-1404
Practice Address - Country:US
Practice Address - Phone:516-520-5280
Practice Address - Fax:516-520-5283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY126210174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW3K442Medicare PIN