Provider Demographics
NPI:1871775726
Name:EAST PATCHOGUE PODIATRY P.C.
Entity type:Organization
Organization Name:EAST PATCHOGUE PODIATRY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KORMYLO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:631-654-5566
Mailing Address - Street 1:285 SILLS RD
Mailing Address - Street 2:BLDG 5-6 #H
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4869
Mailing Address - Country:US
Mailing Address - Phone:631-654-5566
Mailing Address - Fax:
Practice Address - Street 1:285 SILLS RD
Practice Address - Street 2:BLDG 5-6 #H
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4869
Practice Address - Country:US
Practice Address - Phone:631-654-5566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00588743Medicaid
NYT51500Medicare UPIN
NY00588743Medicaid
NY1052870001Medicare NSC