Basic Information
| Provider Information | |||||||||
| NPI: | 1427194992 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STONY BROOK MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 464 NICHOLS RD | ||||||||
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| City: | HAUPPAUGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117885013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319799436 | ||||||||
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| Practice Location | |||||||||
| Address1: | STONY BROOK MEDICAL CENTER | ||||||||
| Address2: | NICHOLLS RD | ||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314442444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HENDERSHOT | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | CERTIFIED REGISTERED NURSE ANESTHET | ||||||||
| AuthorizedOfficialTelephone: | 6314442444 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 501428-1 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.