Provider Demographics
NPI:1972812220
Name:STONY BROOK COMMUNITY MEDICAL, P.C.
Entity Type:Organization
Organization Name:STONY BROOK COMMUNITY MEDICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-638-4018
Mailing Address - Street 1:45 RESEARCH WAY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-6401
Mailing Address - Country:US
Mailing Address - Phone:631-638-4018
Mailing Address - Fax:631-638-4065
Practice Address - Street 1:220 N BELLE MEAD RD
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3523
Practice Address - Country:US
Practice Address - Phone:631-638-4018
Practice Address - Fax:631-638-4065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 207RC0001X, 207RI0011X, 208000000X, 2085R0202X
NY204792207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03319757Medicaid
NY03319757Medicaid