Provider Demographics
NPI:1255472288
Name:SCHREIBER, KENNETH A (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:SCHREIBER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 NESCONSET HWY
Mailing Address - Street 2:SUITE 4
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2631
Mailing Address - Country:US
Mailing Address - Phone:631-928-8331
Mailing Address - Fax:631-928-8331
Practice Address - Street 1:55 NESCONSET HWY
Practice Address - Street 2:SUITE 4
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2631
Practice Address - Country:US
Practice Address - Phone:631-928-8331
Practice Address - Fax:631-928-8331
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1092232084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY641531Medicare ID - Type Unspecified
NYB17435Medicare UPIN