Provider Demographics
NPI:1417998352
Name:NASSAU SUFFOLK MEDICAL PRACTICE, P.C.
Entity Type:Organization
Organization Name:NASSAU SUFFOLK MEDICAL PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANI
Authorized Official - Middle Name:A
Authorized Official - Last Name:BODOUTCHIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-422-3636
Mailing Address - Street 1:120 ROUTE 109
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-6210
Mailing Address - Country:US
Mailing Address - Phone:631-422-3636
Mailing Address - Fax:631-422-2788
Practice Address - Street 1:120 ROUTE 109
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-6210
Practice Address - Country:US
Practice Address - Phone:631-422-3636
Practice Address - Fax:631-422-2788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW7Z461Medicare PIN
NY5443340001Medicare NSC