Provider Demographics
NPI:1578309670
Name:MATHER FACULTY MEDICAL AFFILIATES, UNIVERSITY FACULTY PRACTICE CORPORA
Entity type:Organization
Organization Name:MATHER FACULTY MEDICAL AFFILIATES, UNIVERSITY FACULTY PRACTICE CORPORA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTICIONER
Authorized Official - Prefix:
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCDOWALD
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:631-473-1320
Mailing Address - Street 1:75 N COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2119
Mailing Address - Country:US
Mailing Address - Phone:631-473-1320
Mailing Address - Fax:631-473-7367
Practice Address - Street 1:75 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2119
Practice Address - Country:US
Practice Address - Phone:631-473-1320
Practice Address - Fax:631-473-7367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty