Healthcare Provider Details

I. General information

NPI: 1730408923
Provider Name (Legal Business Name): PHYSICIANS PRIVATE PRACTICE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2010
Last Update Date: 05/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 MIDDLE COUNTRY RD SUITE 103
SMITHTOWN NY
11787-2871
US

IV. Provider business mailing address

222 MIDDLE COUNTRY RD SUITE 103
SMITHTOWN NY
11787-2871
US

V. Phone/Fax

Practice location:
  • Phone: 631-265-2222
  • Fax: 631-265-2227
Mailing address:
  • Phone: 631-265-2222
  • Fax: 631-265-2227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number251788
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number250691
License Number StateNY

VIII. Authorized Official

Name: MARTHA TSARKALIS
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 631-265-2222