Provider Demographics
NPI:1295911741
Name:SOUTH FORK GYNECOLOGY
Entity type:Organization
Organization Name:SOUTH FORK GYNECOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:M
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-329-6500
Mailing Address - Street 1:200 PANTIGO PLACE
Mailing Address - Street 2:SUITE D
Mailing Address - City:EAST HAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11937
Mailing Address - Country:US
Mailing Address - Phone:631-329-6500
Mailing Address - Fax:631-329-7832
Practice Address - Street 1:200 PANTIGO PLACE
Practice Address - Street 2:SUITE D
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937
Practice Address - Country:US
Practice Address - Phone:631-329-6500
Practice Address - Fax:631-329-7832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221321207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty