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General NPI Number Information
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NPI Number | 1265857643
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Entity Type | Organization
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Legal Business Name | CCS MEDICAL PRACTICE, PLLC
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Dates
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Enumeration Date | 02/21/2014
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Last Update Date | 12/16/2019
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Provider Practice Location Address
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Address Line | 17 SOUTHDOWN ROAD
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City | HUNTINGTON
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State | NY
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Zip | 11743
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Country | US
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Telephone | 631-923-2139
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Fax |
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Provider Business Mailing Address
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Address Line | 17 SOUTHDOWN ROAD
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City | HUNTINGTON
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State | NY
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Zip | 11743
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Country | US
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Telephone | 301-809-4000
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL KENNEDY
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Credential | D.O.
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Telephone | 631-923-2139
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251K00000X
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Taxonomy Name | Public Health or Welfare Agency
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License Number | 7175553
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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