Basic Information
| Provider Information | |||||||||
| NPI: | 1972812220 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STONY BROOK COMMUNITY MEDICAL, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45 RESEARCH WAY | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | EAST SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117336401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316384018 | ||||||||
| FaxNumber: | 6316384065 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 N BELLE MEAD RD | ||||||||
| Address2: | |||||||||
| City: | EAST SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117333523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316384018 | ||||||||
| FaxNumber: | 6316384065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2010 | ||||||||
| LastUpdateDate: | 10/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | GRIFFIN | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6316384018 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | 204792 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 03319757 | 05 | NY | MEDICAID |