Provider Demographics
NPI:1659554178
Name:CENTEREACH MEDICAL CARE PC
Entity Type:Organization
Organization Name:CENTEREACH MEDICAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:U
Authorized Official - Last Name:CARBONELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-467-3600
Mailing Address - Street 1:18 EASTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720
Mailing Address - Country:US
Mailing Address - Phone:631-461-3600
Mailing Address - Fax:631-467-3755
Practice Address - Street 1:18 EASTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720
Practice Address - Country:US
Practice Address - Phone:631-461-3600
Practice Address - Fax:631-467-3755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY128949207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA53883Medicare UPIN
NY63F281Medicare Oscar/Certification