Provider Demographics
NPI:1073570776
Name:PANEBIANCO, RICHARD J (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:PANEBIANCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2340
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11969-2340
Mailing Address - Country:US
Mailing Address - Phone:631-283-2100
Mailing Address - Fax:631-283-5731
Practice Address - Street 1:325 MEETING HOUSE LN
Practice Address - Street 2:BLDG #2 SUITE 403
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5087
Practice Address - Country:US
Practice Address - Phone:631-283-2100
Practice Address - Fax:631-283-5731
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1244511207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00653338Medicaid
NY00653338Medicaid
NY316791Medicare ID - Type Unspecified