Basic Information
| Provider Information | |||||||||
| NPI: | 1194737973 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUZZIVALLI | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 635 BELLE TERRE RD | ||||||||
| Address2: | SUITE #204 | ||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117771935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314740008 | ||||||||
| FaxNumber: | 6314740224 | ||||||||
| Practice Location | |||||||||
| Address1: | 635 BELLE TERRE RD | ||||||||
| Address2: | SUITE #204 | ||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117771935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314740008 | ||||||||
| FaxNumber: | 6314740224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 01/27/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 008264 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.