Provider Demographics
NPI:1235436130
Name:GREGORY J DIEHL MD PC
Entity Type:Organization
Organization Name:GREGORY J DIEHL MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DIEHL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-476-7300
Mailing Address - Street 1:11 MEDICAL DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1589
Mailing Address - Country:US
Mailing Address - Phone:631-476-7300
Mailing Address - Fax:631-476-7304
Practice Address - Street 1:11 MEDICAL DR
Practice Address - Street 2:SUITE B
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1589
Practice Address - Country:US
Practice Address - Phone:631-476-7300
Practice Address - Fax:631-476-7304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-12
Last Update Date:2011-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1902162261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1447249214OtherNPI
NY89K831Medicare PIN
NY1447249214OtherNPI