Provider Demographics
NPI:1811187214
Name:PECONIC SURGICAL GROUP, PC
Entity Type:Organization
Organization Name:PECONIC SURGICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLAW
Authorized Official - Middle Name:JOSEF
Authorized Official - Last Name:GREDYSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-369-8539
Mailing Address - Street 1:31 MAIN RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-1953
Mailing Address - Country:US
Mailing Address - Phone:631-369-8539
Mailing Address - Fax:631-369-5613
Practice Address - Street 1:31 MAIN RD
Practice Address - Street 2:SUITE 2
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-1953
Practice Address - Country:US
Practice Address - Phone:631-369-8539
Practice Address - Fax:631-369-5613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175169174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW9M21Medicare PIN