Provider Demographics
NPI:1396178000
Name:PATCHOGUE PEDIATRICS PC
Entity Type:Organization
Organization Name:PATCHOGUE PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHONG-GAYLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-504-6261
Mailing Address - Street 1:264 SILLS RD
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-8804
Mailing Address - Country:US
Mailing Address - Phone:631-504-6261
Mailing Address - Fax:631-504-6263
Practice Address - Street 1:264 SILLS RD
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-8804
Practice Address - Country:US
Practice Address - Phone:631-504-6261
Practice Address - Fax:631-504-6263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-16
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02022351Medicaid