Healthcare Provider Details

I. General information

NPI: 1629969514
Provider Name (Legal Business Name): PETER E KOTSOVOLOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2025
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 OLD COUNTRY RD
PLAINVIEW NY
11803-4914
US

IV. Provider business mailing address

1309 SMITH AVE
NORTH BELLMORE NY
11710-2332
US

V. Phone/Fax

Practice location:
  • Phone: 516-719-3000
  • Fax:
Mailing address:
  • Phone: 631-626-6322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number752812
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number156039
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: