Provider Demographics
NPI:1609204122
Name:STONY CREEK MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:STONY CREEK MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MAYUMI DEANNA
Authorized Official - Middle Name:NODA
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-483-4580
Mailing Address - Street 1:6 BUSINESS PARK DR
Mailing Address - Street 2:SUITE 302
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-2988
Mailing Address - Country:US
Mailing Address - Phone:203-980-1359
Mailing Address - Fax:203-483-4581
Practice Address - Street 1:236 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-3236
Practice Address - Country:US
Practice Address - Phone:203-815-1054
Practice Address - Fax:203-298-9874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-18
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042996207P00000X
CT041818207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty