Provider Demographics
NPI:1447465208
Name:SUFFERN EKG ECHO CARDIOLOGY PC
Entity type:Organization
Organization Name:SUFFERN EKG ECHO CARDIOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, DPFS
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GODINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-987-3945
Mailing Address - Street 1:255 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4812
Mailing Address - Country:US
Mailing Address - Phone:845-987-3952
Mailing Address - Fax:
Practice Address - Street 1:255 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-4812
Practice Address - Country:US
Practice Address - Phone:845-987-3973
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01085730Medicaid
NY01085730Medicaid