Provider Demographics
NPI:1174695068
Name:GENERAL AND VASCULAR SURGERY OF LONG ISLAND PC
Entity type:Organization
Organization Name:GENERAL AND VASCULAR SURGERY OF LONG ISLAND PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:COLANTONIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-346-3355
Mailing Address - Street 1:520 FRANKLIN AVE
Mailing Address - Street 2:SUITE 151
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-5801
Mailing Address - Country:US
Mailing Address - Phone:516-746-3310
Mailing Address - Fax:516-746-5610
Practice Address - Street 1:434 ROCKAWAY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-5636
Practice Address - Country:US
Practice Address - Phone:718-346-2628
Practice Address - Fax:516-248-3044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163260208600000X
207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01616568Medicaid
NY01513024Medicaid