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General NPI Number Information
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NPI Number | 1689334310
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Entity Type | Organization
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Legal Business Name | COASTAL MEDICAL SERVICES OF NY PLLC
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Dates
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Enumeration Date | 12/21/2021
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Last Update Date | 03/14/2023
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Provider Practice Location Address
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Address Line | 1500 ROUTE 112 STE B
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-8055
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Country | US
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Telephone | 917-575-8907
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Fax |
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Provider Business Mailing Address
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Address Line | 1500 ROUTE 112 STE B
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-8055
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GREGORY BREVETTI
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Credential | MD
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Telephone | 917-575-8907
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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