Provider Demographics
NPI:1174556963
Name:ISLAND GASTROENTEROLOGY CONSULTANTS PC
Entity type:Organization
Organization Name:ISLAND GASTROENTEROLOGY CONSULTANTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GASTROENTEROLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:MARIWALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-669-1171
Mailing Address - Street 1:1111 MONTAUK HWY
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4910
Mailing Address - Country:US
Mailing Address - Phone:631-669-1171
Mailing Address - Fax:631-669-1912
Practice Address - Street 1:1111 MONTAUK HWY
Practice Address - Street 2:3RD FLOOR
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4910
Practice Address - Country:US
Practice Address - Phone:631-669-1171
Practice Address - Fax:631-669-1912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143127174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty