Provider Demographics
NPI:1073689477
Name:PORT JEFFERSON OBGYN PC
Entity Type:Organization
Organization Name:PORT JEFFERSON OBGYN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-928-0720
Mailing Address - Street 1:640 BELLE TERRE ROAD
Mailing Address - Street 2:BLDG D
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1936
Mailing Address - Country:US
Mailing Address - Phone:631-928-0720
Mailing Address - Fax:631-928-8620
Practice Address - Street 1:640 BELLE TERRE ROAD
Practice Address - Street 2:BLDG D
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1936
Practice Address - Country:US
Practice Address - Phone:631-928-0720
Practice Address - Fax:631-928-8620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID #