Provider Demographics
NPI:1902965171
Name:SUPREME MEDICAL P.C.
Entity Type:Organization
Organization Name:SUPREME MEDICAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANJANI
Authorized Official - Middle Name:VENKATA
Authorized Official - Last Name:KOTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-751-8905
Mailing Address - Street 1:100 N BELLE MEAD RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3530
Mailing Address - Country:US
Mailing Address - Phone:631-751-8905
Mailing Address - Fax:631-751-8908
Practice Address - Street 1:100 N BELLE MEAD RD
Practice Address - Street 2:SUITE D
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3530
Practice Address - Country:US
Practice Address - Phone:631-751-8905
Practice Address - Fax:631-751-8908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222728207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH91854Medicare UPIN
NY021AQ2Medicare ID - Type Unspecified