Provider Demographics
NPI:1699945378
Name:EASTERN LONG ISLAND SURGERY PC
Entity type:Organization
Organization Name:EASTERN LONG ISLAND SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEDHAT
Authorized Official - Middle Name:E
Authorized Official - Last Name:ALLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-287-6202
Mailing Address - Street 1:365 COUNTY RD 39A
Mailing Address - Street 2:SUITE 11
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968
Mailing Address - Country:US
Mailing Address - Phone:631-287-6202
Mailing Address - Fax:631-287-6213
Practice Address - Street 1:365 COUNTY RD 39A
Practice Address - Street 2:SUITE 11
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968
Practice Address - Country:US
Practice Address - Phone:631-287-6202
Practice Address - Fax:631-287-6213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193888208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty