Provider Demographics
NPI:1336167881
Name:PECONIC ANESTHESIOLOGIST, P.C.
Entity Type:Organization
Organization Name:PECONIC ANESTHESIOLOGIST, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF P.C.
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-548-6220
Mailing Address - Street 1:1300 ROANOKE AVE
Mailing Address - Street 2:P.O. BOX 239
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2031
Mailing Address - Country:US
Mailing Address - Phone:631-548-6220
Mailing Address - Fax:631-208-0988
Practice Address - Street 1:1300 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2031
Practice Address - Country:US
Practice Address - Phone:631-548-6220
Practice Address - Fax:631-208-0988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01610508Medicaid
NY01610508Medicaid