Provider Demographics
NPI:1265857643
Name:CCS MEDICAL PRACTICE, PLLC
Entity Type:Organization
Organization Name:CCS MEDICAL PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-923-2139
Mailing Address - Street 1:17 SOUTHDOWN ROAD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743
Mailing Address - Country:US
Mailing Address - Phone:301-809-4000
Mailing Address - Fax:
Practice Address - Street 1:17 SOUTHDOWN ROAD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743
Practice Address - Country:US
Practice Address - Phone:631-923-2139
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-21
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7175553251K00000X
363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No251K00000XAgenciesPublic Health or Welfare