Healthcare Provider Details

I. General information

NPI: 1699804765
Provider Name (Legal Business Name): CARDIO THORACIC & VASCULAR SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 E MAIN ST SUITE 211
PATCHOGUE NY
11772-3121
US

IV. Provider business mailing address

475 E MAIN ST SUITE 211
PATCHOGUE NY
11772-3121
US

V. Phone/Fax

Practice location:
  • Phone: 631-207-2078
  • Fax: 207-207-2175
Mailing address:
  • Phone: 631-207-2078
  • Fax: 207-207-2175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) 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: DR. SURYA R KUMAR
Title or Position: OWNER
Credential: MD
Phone: 631-207-2078