Provider Demographics
NPI:1417081050
Name:NORTHEAST PODIATRY ASSOC PC
Entity Type:Organization
Organization Name:NORTHEAST PODIATRY ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CUSACK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:631-266-2220
Mailing Address - Street 1:1172 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-2631
Mailing Address - Country:US
Mailing Address - Phone:631-266-2220
Mailing Address - Fax:631-266-5119
Practice Address - Street 1:1172 5TH AVE
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-2631
Practice Address - Country:US
Practice Address - Phone:631-266-2220
Practice Address - Fax:631-266-5119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0862390001Medicare NSC