Provider Demographics
NPI:1033149026
Name:MID ISLAND PRIMARY MEDICAL CARE PC
Entity Type:Organization
Organization Name:MID ISLAND PRIMARY MEDICAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CUSUMANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-735-5454
Mailing Address - Street 1:850 HICKSVILLE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-1300
Mailing Address - Country:US
Mailing Address - Phone:516-735-5454
Mailing Address - Fax:516-735-6121
Practice Address - Street 1:850 HICKSVILLE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-1300
Practice Address - Country:US
Practice Address - Phone:516-735-5454
Practice Address - Fax:516-735-6121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEL711Medicare ID - Type Unspecified