Provider Demographics
NPI:1386649804
Name:CENTRAL SUFFOLK HOSPITAL
Entity Type:Organization
Organization Name:CENTRAL SUFFOLK HOSPITAL
Other - Org Name:PECONIC BAY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT & CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CUSACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-321-6508
Mailing Address - Street 1:1300 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2031
Mailing Address - Country:US
Mailing Address - Phone:631-548-6000
Mailing Address - Fax:631-548-6007
Practice Address - Street 1:1300 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2031
Practice Address - Country:US
Practice Address - Phone:631-548-6000
Practice Address - Fax:631-548-6007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
NY5155000H282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5225-7OtherBC DIALYSIS
NYH03149OtherOXFORD
NY0007461OtherAETNA US HEALTHCARE
NY000250-7OtherBLUE CROSS
NY00274328Medicaid
NY03000300Medicaid
NY330107Medicare Oscar/Certification
NY=========OtherTAX ID COMMERCIALS
NYH03149OtherOXFORD