MENU
MENU
Advanced Surgery Center of Long Island
1500 Route 112
Building 5
Port Jefferson Station, NY 11776
Phone:
(631) 629 - 8822
Make a Payment
Need to make a payment? Please fill out the information below and hit continue.
Error Summary
Please, correctly fill out all required fields.
1. Patient Information
First Name
*
M.I.
Last Name
*
Account Number
Email Address
A receipt will be sent to this email address.
2. Payment Amount
Amount
3. Payment Method
Credit/Debit Card
Bank Account
Name on Card
*
Card Number
*
Expiration Date
*
MM
--
01
02
03
04
05
06
07
08
09
10
11
12
YYYY
--
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
Security Code
*
Zip Code
*
Account Type
Checking
Savings
Routing Number
*
Account Number
*
Name On Check
Check Number
Continue
Cancel