Provider Demographics
NPI:1962516823
Name:WOMENS SURGICAL BOUTIQUE INC
Entity type:Organization
Organization Name:WOMENS SURGICAL BOUTIQUE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:E
Authorized Official - Last Name:LIPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CMF
Authorized Official - Phone:516-292-1320
Mailing Address - Street 1:112 B BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MALVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11565-1652
Mailing Address - Country:US
Mailing Address - Phone:516-292-1320
Mailing Address - Fax:516-292-1323
Practice Address - Street 1:112 B BROADWAY
Practice Address - Street 2:
Practice Address - City:MALVERNE
Practice Address - State:NY
Practice Address - Zip Code:11565-1652
Practice Address - Country:US
Practice Address - Phone:516-292-1320
Practice Address - Fax:516-292-1323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1C4485OtherHEALTH NET
NY0261320001Medicaid
A382561OtherOXFORD
12DME0747NYOtherANTHEM
603482OtherAETNA
AZ00250OtherMDNY
G71541OtherEMPIRE BCBS
AZ00250OtherMDNY