Provider Demographics
NPI:1912944794
Name:STONY BROOK PATHOLOGISTS, UNIVERSITY FACULTY PRACTICE CORPORATION
Entity Type:Organization
Organization Name:STONY BROOK PATHOLOGISTS, UNIVERSITY FACULTY PRACTICE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIR PERSON
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHROYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-444-3000
Mailing Address - Street 1:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0988
Mailing Address - Country:US
Mailing Address - Phone:631-444-3000
Mailing Address - Fax:
Practice Address - Street 1:SUNY @ STONY BROOK
Practice Address - Street 2:BHS, L9, RM 140
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790
Practice Address - Country:US
Practice Address - Phone:631-444-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00821403Medicaid
NYW08961Medicare PIN