Provider Demographics
NPI:1366497448
Name:STONY BROOK RADIOLOGY, UNIVERSITY FACULTY PRACTICE CORPORATION
Entity Type:Organization
Organization Name:STONY BROOK RADIOLOGY, UNIVERSITY FACULTY PRACTICE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIR PERSON
Authorized Official - Prefix:DR
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOULD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-444-3452
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:631-444-3452
Mailing Address - Fax:
Practice Address - Street 1:SUNY AT STONY BRK
Practice Address - Street 2:HSC, L4, RM 120
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8460
Practice Address - Country:US
Practice Address - Phone:631-444-3452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00549133Medicaid
NY00549133Medicaid