Provider Demographics
NPI:1740349927
Name:PREMIER SURGICAL PLLC
Entity type:Organization
Organization Name:PREMIER SURGICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:631-207-2807
Mailing Address - Street 1:40 BRAYTON CT N
Mailing Address - Street 2:
Mailing Address - City:SOUTH SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11720-4625
Mailing Address - Country:US
Mailing Address - Phone:631-475-6663
Mailing Address - Fax:631-475-6664
Practice Address - Street 1:285 SILLS RD
Practice Address - Street 2:BLDG 3 SUITE 2A
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-207-2807
Practice Address - Fax:631-207-5077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221334-1208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH40807Medicare UPIN
NY407I51Medicare ID - Type Unspecified