Basic Information
| Provider Information | |||||||||
| NPI: | 1285750737 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF SUFFOLK | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 SUNRISE HWY STE 124 | ||||||||
| Address2: | POB 9006 | ||||||||
| City: | GREAT RIVER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117391001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318540182 | ||||||||
| FaxNumber: | 6318540199 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 SUNRISE HWY STE 124 | ||||||||
| Address2: | POB 9006 | ||||||||
| City: | GREAT RIVER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117391001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318540182 | ||||||||
| FaxNumber: | 6318540199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 03/19/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | DARLENE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR II | ||||||||
| AuthorizedOfficialTelephone: | 6318540193 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | 5155200R | NY | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 00473170 | 05 | NY | MEDICAID |