Provider Demographics
NPI:1407191364
Name:EAST END PHYSICIAN SERVICES PC
Entity type:Organization
Organization Name:EAST END PHYSICIAN SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT (CORPORATION)
Authorized Official - Prefix:DR
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-765-4150
Mailing Address - Street 1:P.O. BOX 1341
Mailing Address - Street 2:
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971
Mailing Address - Country:US
Mailing Address - Phone:631-765-4150
Mailing Address - Fax:631-765-4688
Practice Address - Street 1:44210 COUNTY RD. 48
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971
Practice Address - Country:US
Practice Address - Phone:631-765-4150
Practice Address - Fax:631-765-4688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-04
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153210-1207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100084348Medicare PIN