Healthcare Provider Details

I. General information

NPI: 1982335907
Provider Name (Legal Business Name): PATCHOGUE MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2022
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N CENTRE AVE
ROCKVILLE CENTRE NY
11570-3937
US

IV. Provider business mailing address

244 5TH AVE STE V273
NEW YORK NY
10001-7604
US

V. Phone/Fax

Practice location:
  • Phone: 646-504-3116
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHELE DAVIS
Title or Position: PARTNER
Credential: DO
Phone: 908-451-5362