Basic Information
| Provider Information | |||||||||
| NPI: | 1841637741 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL SUFFOLK HOSPTIAL | ||||||||
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| OtherOrganizationName: | PECONIC BAY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 ROANOKE AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119012031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315486101 | ||||||||
| FaxNumber: | 6315486007 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 ROANOKE AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119012031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315486101 | ||||||||
| FaxNumber: | 6315486007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2013 | ||||||||
| LastUpdateDate: | 08/31/2016 | ||||||||
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| AuthorizedOfficialLastName: | O'DONNELL | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VP FINANCE/CFO | ||||||||
| AuthorizedOfficialTelephone: | 6315486000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.