Provider Demographics
NPI:1477743599
Name:PATCHOGUE MEDICAL GROUP LLP
Entity Type:Organization
Organization Name:PATCHOGUE MEDICAL GROUP LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:SILVER-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-475-3900
Mailing Address - Street 1:1 E ROE BLVD
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-2631
Mailing Address - Country:US
Mailing Address - Phone:631-475-3900
Mailing Address - Fax:631-475-5166
Practice Address - Street 1:1 E ROE BLVD
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2631
Practice Address - Country:US
Practice Address - Phone:631-475-3900
Practice Address - Fax:631-475-5166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03680820Medicaid
NYA100057597Medicare PIN