MEDICARE: PATCHOGUE PEDIATRICS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396178000
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATCHOGUE PEDIATRICS PC

Provider Business Mailing Address
First Line	:	264 SILLS RD
Second Line	:
City	:	EAST PATCHOGUE
State	:	NY
Zip	:	11772-8804
Country	:	US
Telephone Number	:	631-504-6261
Fax Number	:	631-504-6263

Provider Business Practice Location Address
First Line	:	264 SILLS RD
Second Line	:
City	:	EAST PATCHOGUE
State	:	NY
Zip	:	11772-8804
Country	:	US
Telephone Number	:	631-504-6261
Fax Number	:	631-504-6263

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. AUDREY A CHONG-GAYLE
Credential	:	MD
Telephone Number	:	631-504-6261

Provider Enumeration Date	:	08/16/2013
Last Update Date	:	08/16/2013

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