Provider Demographics
NPI:1043402050
Name:CENTRAL SUFFOLK HOSPITAL
Entity Type:Organization
Organization Name:CENTRAL SUFFOLK HOSPITAL
Other - Org Name:PECONIC BAY MEDICAL CENTER PROFESSIONAL GROUP PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-548-6064
Mailing Address - Street 1:1300 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2031
Mailing Address - Country:US
Mailing Address - Phone:631-548-6116
Mailing Address - Fax:631-548-6007
Practice Address - Street 1:1300 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2031
Practice Address - Country:US
Practice Address - Phone:631-548-6116
Practice Address - Fax:631-548-6007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCE0W708910Medicare PIN