Healthcare Provider Details

I. General information

NPI: 1386884633
Provider Name (Legal Business Name): SOUTH BROOKHAVEN OBSTETRIC & GYNECOLOGIC ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2009
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 W MAIN ST
PATCHOGUE NY
11772-3012
US

IV. Provider business mailing address

444 W MAIN ST
PATCHOGUE NY
11772-3012
US

V. Phone/Fax

Practice location:
  • Phone: 631-475-5250
  • Fax: 631-475-9536
Mailing address:
  • Phone: 631-475-5250
  • Fax: 631-475-9536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
IdentifierA100001644
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name: DR. DAPHNA KILION
Title or Position: PRESIDENT
Credential: M.D.
Phone: 631-475-5250