Provider Demographics
NPI:1902825557
Name:SHROYER, KENNETH REED (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:REED
Last Name:SHROYER
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BST9, ROOM 140, DEPARTMENT OF PATHOLOGY
Mailing Address - Street 2:STONY BROOK UNIVERSITY MEDICAL CENTER
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8691
Mailing Address - Country:US
Mailing Address - Phone:631-444-3069
Mailing Address - Fax:631-444-3424
Practice Address - Street 1:BST9, ROOM 140, DEPARTMENT OF PATHOLOGY
Practice Address - Street 2:STONY BROOK UNIVERSITY MEDICAL CENTER
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8691
Practice Address - Country:US
Practice Address - Phone:631-444-3069
Practice Address - Fax:631-444-3424
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29153207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COE89641Medicare UPIN