Provider Demographics
NPI:1003800715
Name:CUTCHOGUE INTERNAL MEDICINE, PLLC
Entity Type:Organization
Organization Name:CUTCHOGUE INTERNAL MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:IMPELLIZERI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-734-7670
Mailing Address - Street 1:PO BOX 1159
Mailing Address - Street 2:
Mailing Address - City:CUTCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11935-0874
Mailing Address - Country:US
Mailing Address - Phone:631-734-7670
Mailing Address - Fax:631-734-7673
Practice Address - Street 1:32645 MAIN RD
Practice Address - Street 2:
Practice Address - City:CUTCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11935-1364
Practice Address - Country:US
Practice Address - Phone:631-734-7670
Practice Address - Fax:631-734-7670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224524207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02444824Medicaid
WEL451Medicare ID - Type Unspecified
NY02444824Medicaid