Healthcare Provider Details

I. General information

NPI: 1093173262
Provider Name (Legal Business Name): BEVERLY PERRONE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BEVERLY COSTELLO

II. Dates (important events)

Enumeration Date: 02/03/2016
Last Update Date: 07/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 N BELLE MEAD RD
EAST SETAUKET NY
11733-3456
US

IV. Provider business mailing address

931 HALLOCK AVE
PORT JEFFERSON STATION NY
11776-1228
US

V. Phone/Fax

Practice location:
  • Phone: 631-751-3000
  • Fax: 631-751-0506
Mailing address:
  • Phone: 631-331-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number635359
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: