Provider Demographics
NPI:1659848802
Name:SUFFOLK FOOT AND ANKLE
Entity Type:Organization
Organization Name:SUFFOLK FOOT AND ANKLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:KORMYLO
Authorized Official - Suffix:
Authorized Official - Credentials:CPM
Authorized Official - Phone:631-654-5566
Mailing Address - Street 1:285 SILLS RD BLDG 15
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4869
Mailing Address - Country:US
Mailing Address - Phone:631-654-5566
Mailing Address - Fax:631-654-8250
Practice Address - Street 1:1641 ROUTE 112
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-3663
Practice Address - Country:US
Practice Address - Phone:631-447-0800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST PATCHOGUE PODIATRY P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric