Provider Demographics
NPI:1104094556
Name:EDWARD H. CUSSATTI,M.D., P.C.,LLC
Entity type:Organization
Organization Name:EDWARD H. CUSSATTI,M.D., P.C.,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:HUGO
Authorized Official - Last Name:CUSSATTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-422-0909
Mailing Address - Street 1:754 MONTAUK HWY
Mailing Address - Street 2:PO BOX 70
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4908
Mailing Address - Country:US
Mailing Address - Phone:631-422-0909
Mailing Address - Fax:631-422-6660
Practice Address - Street 1:754 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4908
Practice Address - Country:US
Practice Address - Phone:631-422-0909
Practice Address - Fax:631-422-6660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2278601208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW54641Medicare PIN