Healthcare Provider Details

I. General information

NPI: 1295714277
Provider Name (Legal Business Name): TERRYVILLE MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 TERRYVILLE RD
PORT JEFFERSON STATION NY
11776-1329
US

IV. Provider business mailing address

PO BOX 994
PORT JEFFERSON STATION NY
11776-0847
US

V. Phone/Fax

Practice location:
  • Phone: 631-928-2002
  • Fax: 631-928-4934
Mailing address:
  • Phone: 631-928-2002
  • Fax: 631-928-4934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number09600
License Number StateNY

VIII. Authorized Official

Name: DR. JOHN BIASETTI
Title or Position: PARTNER
Credential: M.D.
Phone: 631-928-2002