Provider Demographics
NPI:1780857276
Name:FAIREY, GEORGE G (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:G
Last Name:FAIREY
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 1:1227 MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2227
Mailing Address - Country:US
Mailing Address - Phone:631-689-5155
Mailing Address - Fax:
Practice Address - Street 1:1227 MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2227
Practice Address - Country:US
Practice Address - Phone:631-689-5155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1299722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00509146Medicaid
NY19A981Medicare PIN
NYC06532Medicare UPIN