Healthcare Provider Details

I. General information

NPI: 1821177981
Provider Name (Legal Business Name): BROOKHAVEN CARDIAC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 E MAIN ST SUITE 205
PATCHOGUE NY
11772-3121
US

IV. Provider business mailing address

475 E MAIN ST SUITE 205
PATCHOGUE NY
11772-3121
US

V. Phone/Fax

Practice location:
  • Phone: 631-654-2386
  • Fax: 631-447-3852
Mailing address:
  • Phone: 631-654-2386
  • Fax: 631-447-3852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SOMA PULIPATI
Title or Position: MD
Credential: MD
Phone: 631-654-2386