Provider Demographics
NPI:1083839617
Name:EASTERN LONG ISLAND GENERAL AND VASCULAR SURGERY PC
Entity Type:Organization
Organization Name:EASTERN LONG ISLAND GENERAL AND VASCULAR SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:RICCA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-287-6570
Mailing Address - Street 1:335A MEETING HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-5051
Mailing Address - Country:US
Mailing Address - Phone:631-287-6570
Mailing Address - Fax:631-287-6578
Practice Address - Street 1:335A MEETING HOUSE LN
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5051
Practice Address - Country:US
Practice Address - Phone:631-287-6570
Practice Address - Fax:631-287-6578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143299174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWCL711Medicare PIN