1982659470 NPI number — STONY BROOK FAMILY AND PREVENTIVE MEDICINE, UNIVERSITY FACULTY PRACTIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982659470 NPI number — STONY BROOK FAMILY AND PREVENTIVE MEDICINE, UNIVERSITY FACULTY PRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STONY BROOK FAMILY AND PREVENTIVE MEDICINE, UNIVERSITY FACULTY PRACTIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982659470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1554
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STONY BROOK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11790-0988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-444-2306
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
SUNY @ STONY BROOK
Provider Second Line Business Practice Location Address:
HSC, L4, RM 050
Provider Business Practice Location Address City Name:
STONY BROOK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11794-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-444-2306
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRANEK
Authorized Official First Name:
IRIS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHAIRPERSON
Authorized Official Telephone Number:
631-444-2306

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00549880 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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