Provider Demographics
NPI:1700020260
Name:ANNETTE RACANIELLO D O P C
Entity type:Organization
Organization Name:ANNETTE RACANIELLO D O P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:RACANIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-286-2355
Mailing Address - Street 1:PO BOX 78
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11719-0078
Mailing Address - Country:US
Mailing Address - Phone:631-286-2355
Mailing Address - Fax:631-286-6808
Practice Address - Street 1:1 ANDIRON LN
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11719-9534
Practice Address - Country:US
Practice Address - Phone:631-286-2355
Practice Address - Fax:631-286-6808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-28
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157578207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01153048Medicaid
NY03197073Medicaid
NY03197073Medicaid
NY33F971Medicare PIN
NY01153048Medicaid