Healthcare Provider Details

I. General information

NPI: 1932688629
Provider Name (Legal Business Name): PECONIC CARDIOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2018
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 ROANOKE AVE
RIVERHEAD NY
11901-2724
US

IV. Provider business mailing address

951 ROANOKE AVE
RIVERHEAD NY
11901-2724
US

V. Phone/Fax

Practice location:
  • Phone: 631-727-7773
  • Fax: 631-727-7832
Mailing address:
  • Phone: 631-727-7773
  • Fax: 631-727-7832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MICHELE LEE CUSACK
Title or Position: SENIOR VICE PRESIDENT & CFO
Credential:
Phone: 516-321-6058