Provider Demographics
NPI:1083745566
Name:GASTROENTEROLOGY ASSOCIATES OF SUFFOLK PC
Entity Type:Organization
Organization Name:GASTROENTEROLOGY ASSOCIATES OF SUFFOLK PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:ALBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-331-7200
Mailing Address - Street 1:931 HALLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1228
Mailing Address - Country:US
Mailing Address - Phone:631-331-7200
Mailing Address - Fax:631-331-8636
Practice Address - Street 1:931 HALLOCK AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1228
Practice Address - Country:US
Practice Address - Phone:631-331-7200
Practice Address - Fax:631-331-8636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW18451Medicare ID - Type Unspecified