Basic Information
| Provider Information | |||||||||
| NPI: | 1679823512 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHS PHYSICIAN PARTNERS, P.C | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GREAT SOUTH BAY MEDICAL PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95000-6625 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191956625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314656297 | ||||||||
| FaxNumber: | 6314656524 | ||||||||
| Practice Location | |||||||||
| Address1: | 213 MONTAUK HWY | ||||||||
| Address2: | |||||||||
| City: | WEST SAYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117961800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315636205 | ||||||||
| FaxNumber: | 6315637718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2012 | ||||||||
| LastUpdateDate: | 07/18/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SOTERAKIS | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5165626231 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHS PHYSICIAN PARTNERS, PC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.