Provider Demographics
NPI:1407939374
Name:NORTH SHORE INTERNAL MEDICINE ASSOCIATES, P.C.
Entity type:Organization
Organization Name:NORTH SHORE INTERNAL MEDICINE ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JODIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOM-GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-482-0600
Mailing Address - Street 1:560 NORTHERN BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5100
Mailing Address - Country:US
Mailing Address - Phone:516-482-0600
Mailing Address - Fax:
Practice Address - Street 1:560 NORTHERN BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5100
Practice Address - Country:US
Practice Address - Phone:516-482-0600
Practice Address - Fax:516-829-9674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207R00000X
207RC0000X, 207RG0100X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW13421Medicare ID - Type Unspecified