Basic Information
| Provider Information | |||||||||
| NPI: | 1841683281 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PECONIC BAY MEDICAL SERVICES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 185 OLD COUNTRY RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119012121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312984479 | ||||||||
| FaxNumber: | 6315913047 | ||||||||
| Practice Location | |||||||||
| Address1: | 496 COUNTY ROAD 111 | ||||||||
| Address2: | BUILDING F | ||||||||
| City: | MANORVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119493383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314053200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2015 | ||||||||
| LastUpdateDate: | 03/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | KUBIAK | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6315486470 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.