Provider Demographics
NPI:1902088495
Name:MEETING HOUSE LANE MEDICAL PRACTICE PC
Entity Type:Organization
Organization Name:MEETING HOUSE LANE MEDICAL PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDRICK
Authorized Official - Middle Name:I
Authorized Official - Last Name:WEINBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-726-8332
Mailing Address - Street 1:57 HAMPTON RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-4973
Mailing Address - Country:US
Mailing Address - Phone:631-283-2430
Mailing Address - Fax:631-283-7496
Practice Address - Street 1:57 HAMPTON RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-4973
Practice Address - Country:US
Practice Address - Phone:631-283-2430
Practice Address - Fax:631-283-7496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY031402436Medicaid
NY031402436Medicaid