Provider Demographics
NPI:1306996954
Name:GREAT SOUTH BAY OTOLARYNGOLOGY PC
Entity type:Organization
Organization Name:GREAT SOUTH BAY OTOLARYNGOLOGY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GARGANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-665-2430
Mailing Address - Street 1:375 E MAIN ST
Mailing Address - Street 2:SUITE 17
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8418
Mailing Address - Country:US
Mailing Address - Phone:631-665-2430
Mailing Address - Fax:631-665-2342
Practice Address - Street 1:375 E MAIN ST
Practice Address - Street 2:SUITE 17
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8418
Practice Address - Country:US
Practice Address - Phone:631-665-2430
Practice Address - Fax:631-665-2342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWX0952Medicare PIN
NYWX0951Medicare PIN