Provider Demographics
NPI:1275833477
Name:MBODY MINIMALLY INVASIVE SURGERY, PC
Entity type:Organization
Organization Name:MBODY MINIMALLY INVASIVE SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O. - MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:NICK
Authorized Official - Middle Name:H
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-591-3992
Mailing Address - Street 1:365 COUNTY ROAD 39A
Mailing Address - Street 2:SUITE 11
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-5284
Mailing Address - Country:US
Mailing Address - Phone:631-591-3992
Mailing Address - Fax:631-591-0206
Practice Address - Street 1:365 COUNTY ROAD 39A
Practice Address - Street 2:SUITE 11
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5284
Practice Address - Country:US
Practice Address - Phone:631-591-3992
Practice Address - Fax:631-591-0206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-22
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200259208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty