Provider Demographics
NPI:1073603734
Name:GEORGE G. FAIREY MD
Entity Type:Organization
Organization Name:GEORGE G. FAIREY MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:G
Authorized Official - Last Name:FAIREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-689-5155
Mailing Address - Street 1:1212 N COUNTRY RD STE 2A
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-1919
Mailing Address - Country:US
Mailing Address - Phone:631-689-5155
Mailing Address - Fax:
Practice Address - Street 1:1212 N COUNTRY RD STE 2A
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-1919
Practice Address - Country:US
Practice Address - Phone:631-689-5155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129972101YM0800X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Not Answered261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00509146Medicaid
NY00509146Medicaid
NYC06532Medicare UPIN