MEDICARE: SUFFOLK FOOT AND ANKLE

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	261QP1100X	Podiatric Clinic/Center

General Provider Information

NPI Number	:	1659848802
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUFFOLK FOOT AND ANKLE

Provider Business Mailing Address
First Line	:	285 SILLS RD BLDG 15
Second Line	:
City	:	EAST PATCHOGUE
State	:	NY
Zip	:	11772-4869
Country	:	US
Telephone Number	:	631-654-5566
Fax Number	:	631-654-8250

Provider Business Practice Location Address
First Line	:	1641 ROUTE 112
Second Line	:
City	:	MEDFORD
State	:	NY
Zip	:	11763-3663
Country	:	US
Telephone Number	:	631-447-0800
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. EDWARD J KORMYLO
Credential	:	CPM
Telephone Number	:	631-654-5566

Provider Enumeration Date	:	10/25/2018
Last Update Date	:	10/25/2018

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Directions to “SUFFOLK FOOT AND ANKLE ” Practice Location

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