NPIMap

Organization Active NPI

South Nassau Physician Practice PC

  • Surgery Physician
  • Valley Stream, NY
National Provider Identifier
1962652685
Registry record updated Sep 30, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Surgery PhysicianTaxonomy code 208600000X
License
201327 Issued in NY
Legal business name
SOUTH NASSAU PHYSICIAN PRACTICE PC
Practice address
1 S Central Ave
Valley Stream, NY 11580-5443
Phone
(516) 632-3350
Fax
(516) 632-3355
NPI assigned
Sep 30, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 30, 2008

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

Authorized official

Name
Rajiv V Datta, MD
Title
Director
Phone
(516) 632-3350

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Surgery PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 208600000X 201327 NY Primary
Surgery PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 208600000X 200879 NY
Surgery PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 208600000X 242239 NY

Addresses

Primary practice location

1 S Central Ave
Valley Stream, NY 11580-5443

Mailing address

1 S Central Ave
Valley Stream, NY 11580-5443
Phone (516) 632-3350

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110504000787 NY Part B Supplier - Clinic/Group Practice 9931384088 Receives reassigned benefits from 25 practitioners
Practice locations: Bellmore, NY; Freeport, NY; Greenlawn, NY; Lawrence, NY; Merrick, NY; Oceanside, NY; Valley Stream, NY

National Provider Directory

National Provider Directory

Locations

155 W Merrick Rd
Ste 204
Freeport, NY 11520
Phone (516) 867-0102

155 W Merrick Rd
Ste 101
Freeport, NY 11520
Phone (516) 379-3139

Practitioners & affiliated clinicians

Practitioners 26

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 26

NPI Registry JSON

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

{
    "created_epoch": "1222732800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1222732800000",
    "number": "1962652685",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 S CENTRAL AVE",
            "city": "VALLEY STREAM",
            "state": "NY",
            "postal_code": "115805443",
            "telephone_number": "516-632-3350",
            "fax_number": "516-632-3355"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 S CENTRAL AVE",
            "city": "VALLEY STREAM",
            "state": "NY",
            "postal_code": "115805443",
            "telephone_number": "516-632-3350",
            "fax_number": "516-632-3355"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH NASSAU PHYSICIAN PRACTICE PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-09-30",
        "last_updated": "2008-09-30",
        "status": "A",
        "authorized_official_last_name": "DATTA",
        "authorized_official_first_name": "RAJIV",
        "authorized_official_middle_name": "V",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "516-632-3350",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Surgery",
            "state": "NY",
            "license": "201327",
            "primary": true
        },
        {
            "code": "208600000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Surgery",
            "state": "NY",
            "license": "200879",
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Surgery",
            "state": "NY",
            "license": "242239",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Valley Stream, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 30, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.