Provider Demographics
NPI:1912163346
Name:MATHEW M. CHACKO PHYSICIAN PC
Entity Type:Organization
Organization Name:MATHEW M. CHACKO PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:MELOOTTU
Authorized Official - Last Name:CHACKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-360-0303
Mailing Address - Street 1:222 E MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2871
Mailing Address - Country:US
Mailing Address - Phone:631-360-0303
Mailing Address - Fax:631-360-2815
Practice Address - Street 1:222 E MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2871
Practice Address - Country:US
Practice Address - Phone:631-360-0303
Practice Address - Fax:631-360-2815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
42D571Medicare PIN