Provider Demographics
NPI:1740276898
Name:PECONIC GASTROENTEROLOGY PC
Entity type:Organization
Organization Name:PECONIC GASTROENTEROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:NASO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-283-0090
Mailing Address - Street 1:223 HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-5027
Mailing Address - Country:US
Mailing Address - Phone:631-283-0090
Mailing Address - Fax:631-287-1037
Practice Address - Street 1:223 HAMPTON RD
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5027
Practice Address - Country:US
Practice Address - Phone:631-283-0090
Practice Address - Fax:631-287-1037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01936089Medicaid
NYW32371Medicare PIN