Healthcare Provider Details

I. General information

NPI: 1477893113
Provider Name (Legal Business Name): VASCULAR SURGERY ASSOCIATE OF SUFFOLK COUNTY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2013
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 MEDFORD AVE STE A
PATCHOGUE NY
11772-1222
US

IV. Provider business mailing address

33 MEDFORD AVE STE A
PATCHOGUE NY
11772-1222
US

V. Phone/Fax

Practice location:
  • Phone: 631-569-5410
  • Fax: 631-569-5413
Mailing address:
  • Phone: 631-569-5410
  • Fax: 631-569-5413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIELLE COWAN
Title or Position: MANAGER
Credential:
Phone: 631-569-5410