Healthcare Provider Details

I. General information

NPI: 1497591507
Provider Name (Legal Business Name): PECONIC BAY FACULTY MEDICAL AFFILIATES, UNIVERSITY FACULTY PRACTICE CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HEROES WAY
RIVERHEAD NY
11901-2054
US

IV. Provider business mailing address

1 HEROES WAY
RIVERHEAD NY
11901-2054
US

V. Phone/Fax

Practice location:
  • Phone: 631-548-6063
  • Fax: 631-548-6007
Mailing address:
  • Phone: 631-548-6063
  • Fax: 631-548-6007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER A MEYER
Title or Position: NURSE PRACTICIONER
Credential: NP
Phone: 631-548-6063