Basic Information
| Provider Information | |||||||||
| NPI: | 1336167881 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PECONIC ANESTHESIOLOGIST, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 ROANOKE AVE | ||||||||
| Address2: | P.O. BOX 239 | ||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119012031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315486220 | ||||||||
| FaxNumber: | 6312080988 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 ROANOKE AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119012031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315486220 | ||||||||
| FaxNumber: | 6312080988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WARD | ||||||||
| AuthorizedOfficialFirstName: | ROY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT OF P.C. | ||||||||
| AuthorizedOfficialTelephone: | 6315486220 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 01610508 | 05 | NY | MEDICAID |