Provider Demographics
NPI:1164478749
Name:STONY BROOK PREVENTIVE MEDICINE SERVICES, UNIV FCLTY PRACTICE CORP
Entity Type:Organization
Organization Name:STONY BROOK PREVENTIVE MEDICINE SERVICES, UNIV FCLTY PRACTICE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRANEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-444-2189
Mailing Address - Street 1:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0988
Mailing Address - Country:US
Mailing Address - Phone:631-444-2189
Mailing Address - Fax:
Practice Address - Street 1:SUNY @ STONY BROOK
Practice Address - Street 2:HSC, L3, RM 086
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-444-2189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00994812Medicaid
NYW12841Medicare PIN