MEDICARE: CUTCHOGUE INTERNAL MEDICINE, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	224524	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003800715
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CUTCHOGUE INTERNAL MEDICINE, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 1159
Second Line	:
City	:	CUTCHOGUE
State	:	NY
Zip	:	11935-0874
Country	:	US
Telephone Number	:	631-734-7670
Fax Number	:	631-734-7673

Provider Business Practice Location Address
First Line	:	32645 MAIN RD
Second Line	:
City	:	CUTCHOGUE
State	:	NY
Zip	:	11935-1364
Country	:	US
Telephone Number	:	631-734-7670
Fax Number	:	631-734-7670

Authorized Official
Title or Position	:	MANGING MEMBER
Name	:	JOHN IMPELLIZERI
Credential	:	D.O.
Telephone Number	:	631-734-7670

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	08/22/2020

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