Provider Demographics
NPI:1295780112
Name:STONY BROOK RADIOLOGIC SERVICES PC
Entity type:Organization
Organization Name:STONY BROOK RADIOLOGIC SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-231-0300
Mailing Address - Street 1:2500 NESCONSET HWY
Mailing Address - Street 2:SUITE 15A
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2555
Mailing Address - Country:US
Mailing Address - Phone:631-751-2900
Mailing Address - Fax:631-751-2051
Practice Address - Street 1:2500 NESCONSET HWY
Practice Address - Street 2:SUITE 15A
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2555
Practice Address - Country:US
Practice Address - Phone:631-751-2900
Practice Address - Fax:631-751-2051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02284260Medicaid
NY02284260Medicaid