Provider Demographics
NPI:1174965727
Name:SUFFOLK PRIMARY HEALTH, LLC
Entity type:Organization
Organization Name:SUFFOLK PRIMARY HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GAUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-473-7100
Mailing Address - Street 1:170 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2198
Mailing Address - Country:US
Mailing Address - Phone:631-208-4460
Mailing Address - Fax:631-208-4462
Practice Address - Street 1:170 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2198
Practice Address - Country:US
Practice Address - Phone:631-208-4460
Practice Address - Fax:631-208-4462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-24
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QP2300X
NY5155205R261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6361OtherNYS FACILITY ID
NY5155205ROtherNYS DOH OPCERT