Provider Demographics
NPI:1316160658
Name:ISLAND MEDICAL OF MEDFORD, LLP
Entity type:Organization
Organization Name:ISLAND MEDICAL OF MEDFORD, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISSETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CEPEDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-758-2220
Mailing Address - Street 1:1647 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3635
Mailing Address - Country:US
Mailing Address - Phone:631-758-2220
Mailing Address - Fax:631-758-8355
Practice Address - Street 1:1647 ROUTE 112
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-3635
Practice Address - Country:US
Practice Address - Phone:631-758-2220
Practice Address - Fax:631-758-8355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH32122Medicare UPIN
NYF14567Medicare UPIN
NYE48887Medicare UPIN
NYWER921Medicare ID - Type UnspecifiedISLAND MEDICAL OF MEDFORD
NYF21669Medicare UPIN
NYC12254Medicare UPIN
NYG62980Medicare UPIN
NYH11650Medicare UPIN