Northeast Breast Reconstruction LLC

Primary specialty

Plastic and Reconstructive Surgery PhysicianTaxonomy code 2086S0122X

License

25MA10021400 Issued in NJ

Legal business name

NORTHEAST BREAST RECONSTRUCTION LLC

Practice address

21 Southport Terrace
Southport, CT 06890

Phone

(718) 672-2824

Fax

(718) 672-3280

NPI assigned

Feb 6, 2017

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Shareef Jandali, M.D.

Title

Owner

Phone

(718) 672-2824

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1486339200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1486339200000",
    "number": "1255879748",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "21 SOUTHPORT TERRACE",
            "city": "SOUTHPORT",
            "state": "CT",
            "postal_code": "06890",
            "telephone_number": "718-672-2824",
            "fax_number": "718-672-3280"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "21 SOUTHPORT TERRACE",
            "city": "SOUTHPORT",
            "state": "CT",
            "postal_code": "06890",
            "telephone_number": "718-672-2824",
            "fax_number": "718-672-3280"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEAST BREAST RECONSTRUCTION LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-02-06",
        "last_updated": "2017-02-06",
        "status": "A",
        "authorized_official_last_name": "JANDALI",
        "authorized_official_first_name": "SHAREEF",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "718-672-2824",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "2086S0122X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Surgery, Plastic and Reconstructive Surgery",
            "state": "NJ",
            "license": "25MA10021400",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Plastic and Reconstructive Surgery Physician in Southport, CT
• Providers in Southport, CT by specialty
• Plastic and Reconstructive Surgery Physician in Connecticut

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 6, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.