Provider Demographics
NPI:1841334968
Name:PORT JEFFERSON EMERGENCY MEDICAL CARE
Entity type:Organization
Organization Name:PORT JEFFERSON EMERGENCY MEDICAL CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KONCZYNIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-689-2700
Mailing Address - Street 1:PO BOX 438
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-0438
Mailing Address - Country:US
Mailing Address - Phone:631-689-2700
Mailing Address - Fax:631-689-7557
Practice Address - Street 1:7 S JERSEY AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2065
Practice Address - Country:US
Practice Address - Phone:631-689-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW22101Medicare ID - Type Unspecified