Healthcare Provider Details

I. General information

NPI: 1417045519
Provider Name (Legal Business Name): NORTH COUNTRY COLORECTAL SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 N COUNTRY RD
PORT JEFFERSON NY
11777-2160
US

IV. Provider business mailing address

41 N COUNTRY RD
PORT JEFFERSON NY
11777-2160
US

V. Phone/Fax

Practice location:
  • Phone: 631-331-4672
  • Fax: 631-331-4239
Mailing address:
  • Phone: 631-331-4672
  • Fax: 631-331-4239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number206665
License Number StateNY

VIII. Authorized Official

Name: DR. MARIA A BASILE
Title or Position: OWNER
Credential: M.D.
Phone: 631-331-4672