Provider Demographics
NPI:1770919763
Name:SOUTHWEST SUFFOLK MEDICAL PC
Entity type:Organization
Organization Name:SOUTHWEST SUFFOLK MEDICAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-465-6001
Mailing Address - Street 1:502 S WELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-4925
Mailing Address - Country:US
Mailing Address - Phone:631-226-8600
Mailing Address - Fax:
Practice Address - Street 1:502 S WELLWOOD AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4925
Practice Address - Country:US
Practice Address - Phone:631-226-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-23
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty