Provider Demographics
NPI:1407844160
Name:ISLAND MEDICAL SPECIALISTS, P.L.L.C.
Entity type:Organization
Organization Name:ISLAND MEDICAL SPECIALISTS, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-876-6220
Mailing Address - Street 1:2627 HYLAN BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-4344
Mailing Address - Country:US
Mailing Address - Phone:718-351-1136
Mailing Address - Fax:718-667-9711
Practice Address - Street 1:2627 HYLAN BLVD STE C
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-4344
Practice Address - Country:US
Practice Address - Phone:718-351-1136
Practice Address - Fax:718-667-9711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207R00000X, 207RC0000X, 207R00000X
NY=========207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02679945Medicaid
NY02679945Medicaid