Basic Information
| Provider Information | |||||||||
| NPI: | 1487620613 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PECONIC BAY PRIMARY MEDICAL CARE, PC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SAME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13400 MAIN RD | ||||||||
| Address2: | PO BOX 1619 | ||||||||
| City: | MATTITUCK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119523209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312984479 | ||||||||
| FaxNumber: | 6312984236 | ||||||||
| Practice Location | |||||||||
| Address1: | 13400 MAIN RD | ||||||||
| Address2: | |||||||||
| City: | MATTITUCK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119523209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312984008 | ||||||||
| FaxNumber: | 6312985969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 07/07/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KUBIAK | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6315486000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01714209 | 05 | NY | MEDICAID |