11 Medical Drive Wellness PLLC

Primary specialty

Emergency Medical Services (Emergency Medicine) PhysicianTaxonomy code 207PE0004X

Legal business name

11 MEDICAL DRIVE WELLNESS PLLC

Practice address

11 Medical Dr
Suite B
Port Jefferson Station, NY 11776-1589

Phone

(631) 509-6066

Fax

(631) 849-5824

NPI assigned

May 3, 2017

Last updated

May 3, 2017By the provider in NPPES

Organization subpart

Yes

Parent organization

DH MANAGEMENT GROUP LLCAs reported in NPPES

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

Authorized official

Name

Laura Roy

Title

Practice Manager

Phone

(631) 805-6384

Specialties & licenses 1

Addresses

Part of

Holistic Medical Wellness PLLC

Locations

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

{
    "created_epoch": "1493769600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1493769600000",
    "number": "1902332588",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11 MEDICAL DR",
            "address_2": "SUITE B",
            "city": "PORT JEFFERSON STATION",
            "state": "NY",
            "postal_code": "117761589",
            "telephone_number": "631-509-6066",
            "fax_number": "631-849-5824"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11 MEDICAL DR",
            "address_2": "SUITE B",
            "city": "PORT JEFFERSON STATION",
            "state": "NY",
            "postal_code": "117761589",
            "telephone_number": "631-509-6066",
            "fax_number": "631-849-5824"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "11 MEDICAL DRIVE WELLNESS PLLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "DH MANAGEMENT GROUP LLC",
        "enumeration_date": "2017-05-03",
        "last_updated": "2017-05-03",
        "status": "A",
        "authorized_official_last_name": "ROY",
        "authorized_official_first_name": "LAURA",
        "authorized_official_title_or_position": "PRACTICE MANAGER",
        "authorized_official_telephone_number": "631-805-6384"
    },
    "taxonomies": [
        {
            "code": "207PE0004X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine, Emergency Medical Services",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Emergency Medical Services (Emergency Medicine) Physician in Port Jefferson Station, NY
• Providers in Port Jefferson Station, NY by specialty
• Emergency Medical Services (Emergency Medicine) Physician in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 3, 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.