Provider Demographics
NPI:1912460791
Name:PORT JEFFERSON SURGICAL PC
Entity Type:Organization
Organization Name:PORT JEFFERSON SURGICAL PC
Other - Org Name:PORT MD MEDICAL WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:MARKELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-403-4310
Mailing Address - Street 1:70 N COUNTRY RD STE 201
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1227 MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2227
Practice Address - Country:US
Practice Address - Phone:718-554-1042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-09
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center