Provider Demographics
NPI:1619377488
Name:TOTAL MEDICAL HEALTHCARE PC
Entity Type:Organization
Organization Name:TOTAL MEDICAL HEALTHCARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIMOS
Authorized Official - Middle Name:
Authorized Official - Last Name:KANAKOUDAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-824-1380
Mailing Address - Street 1:665 TREEHOUSE CIR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-6837
Mailing Address - Country:US
Mailing Address - Phone:904-654-2410
Mailing Address - Fax:904-417-7177
Practice Address - Street 1:550 E MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2672
Practice Address - Country:US
Practice Address - Phone:631-591-3093
Practice Address - Fax:631-317-1010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-29
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60 257261207Q00000X
NY33 337755363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty