Healthcare Provider Details

I. General information

NPI: 1942484423
Provider Name (Legal Business Name): SUFFOLK ORTHOPAEDIC ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 09/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 E MAIN ST STE 1
BAY SHORE NY
11706-8418
US

IV. Provider business mailing address

375 E MAIN ST STE 1
BAY SHORE NY
11706-8418
US

V. Phone/Fax

Practice location:
  • Phone: 631-665-8790
  • Fax: 631-665-1581
Mailing address:
  • Phone: 631-665-8790
  • Fax: 631-665-1581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD J TABERSHAW
Title or Position: PRESIDENT
Credential: MD
Phone: 631-665-8790