1184679342 NPI number — STONY BROOK INTERNISTS, UNIVERSITY FACULTY PRACTICE CORPORATION

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 1184679342 NPI number — STONY BROOK INTERNISTS, UNIVERSITY FACULTY PRACTICE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STONY BROOK INTERNISTS, UNIVERSITY FACULTY PRACTICE CORPORATION
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:
1184679342
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2013
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:
631-444-2448
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, L16, RM 020
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:
631-444-2448
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YANG
Authorized Official First Name:
VINCENT
Authorized Official Middle Name:
Authorized Official Title or Position:
CHAIR PERSON
Authorized Official Telephone Number:
631-444-2448

Provider Taxonomy Codes

  • Taxonomy code: 207RX0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00615265 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: CB8937 . This is a "RAILROAD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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