Provider Demographics
NPI:1225204621
Name:NORTH SHORE MEDICAL GROUP, PC
Entity type:Organization
Organization Name:NORTH SHORE MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-328-3888
Mailing Address - Street 1:2035 LAKEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1661
Mailing Address - Country:US
Mailing Address - Phone:516-328-3888
Mailing Address - Fax:516-352-6579
Practice Address - Street 1:2035 LAKEVILLE RD
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1661
Practice Address - Country:US
Practice Address - Phone:516-328-3888
Practice Address - Fax:516-352-6579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120996207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty