Basic Information
| Provider Information | |||||||||
| NPI: | 1386649804 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL SUFFOLK HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PECONIC BAY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 ROANOKE AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119012031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315486000 | ||||||||
| FaxNumber: | 6315486007 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 ROANOKE AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119012031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315486000 | ||||||||
| FaxNumber: | 6315486007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 08/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CUSACK | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 5163216508 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | N | Agencies | Home Health | 282N00000X | 5155000H | NY | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 5225-7 | 01 | NY | BC DIALYSIS | OTHER | H03149 | 01 | NY | OXFORD | OTHER | 0007461 | 01 | NY | AETNA US HEALTHCARE | OTHER | 000250-7 | 01 | NY | BLUE CROSS | OTHER | 00274328 | 05 | NY | MEDICAID | 03000300 | 05 | NY | MEDICAID |