Provider Demographics
NPI:1770754020
Name:SUFFOLK COUNTY FOOT CARE PLLC
Entity type:Organization
Organization Name:SUFFOLK COUNTY FOOT CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:RAVITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:631-269-4600
Mailing Address - Street 1:63 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-2706
Mailing Address - Country:US
Mailing Address - Phone:631-269-4600
Mailing Address - Fax:631-269-0801
Practice Address - Street 1:63 MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-2706
Practice Address - Country:US
Practice Address - Phone:631-269-4600
Practice Address - Fax:631-269-0801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0478480001Medicare NSC