Provider Demographics
NPI:1215952072
Name:PORT JEFF MEDICAL CARE, PC
Entity type:Organization
Organization Name:PORT JEFF MEDICAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MORMANDO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-642-2025
Mailing Address - Street 1:410 HALLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1232
Mailing Address - Country:US
Mailing Address - Phone:631-642-1100
Mailing Address - Fax:631-642-1190
Practice Address - Street 1:410 HALLOCK AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1232
Practice Address - Country:US
Practice Address - Phone:631-642-1100
Practice Address - Fax:631-642-1190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200407207R00000X
NY178674207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WEE551Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER