Healthcare Provider Details

I. General information

NPI: 1184505299
Provider Name (Legal Business Name): SMITHTOWN ASC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 SOUTHERN BLVD STE 1-4
NESCONSET NY
11767-1089
US

IV. Provider business mailing address

61 SOUTHERN BLVD STE 1-4
NESCONSET NY
11767-1089
US

V. Phone/Fax

Practice location:
  • Phone: 111-111-1111
  • Fax:
Mailing address:
  • Phone: 631-546-0802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BILLY INGRAM
Title or Position: MEMBER
Credential:
Phone: 267-455-4855