Provider Demographics
NPI:1427139815
Name:LEVINE, PHILIP ELIEZER (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:ELIEZER
Last Name:LEVINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21111 NORTHERN BLVD
Mailing Address - Street 2:PREMIER HEALTHCARE
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3241
Mailing Address - Country:US
Mailing Address - Phone:718-705-1000
Mailing Address - Fax:718-224-1767
Practice Address - Street 1:21111 NORTHERN BLVD
Practice Address - Street 2:PREMIER HEALTHCARE
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3241
Practice Address - Country:US
Practice Address - Phone:718-705-1000
Practice Address - Fax:718-224-1767
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1277742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY127774OtherMEDICAL LICENSE
NY00375631Medicaid
NYCO5086Medicare UPIN