Healthcare Provider Details

I. General information

NPI: 1467654822
Provider Name (Legal Business Name): MICHAEL F CUCCINIELLO C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MONTAUK HWY.
QUOGUE NY
11959-1782
US

IV. Provider business mailing address

PO BOX 1782
QUOGUE NY
11959-1782
US

V. Phone/Fax

Practice location:
  • Phone: 631-653-6112
  • Fax: 631-653-5899
Mailing address:
  • Phone: 631-653-6112
  • Fax: 631-653-5899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number328551-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: