Basic Information
| Provider Information | |||||||||
| NPI: | 1699720888 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEUROLOGY ASSOCIATES OF STONY BROOK, UNIVERSITY FACULTY PRACTICE CORPO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1554 | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117900988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314448462 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 NICOLLS RD RM 20 | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117940001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314442599 | ||||||||
| FaxNumber: | 6314414744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 09/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | HALTERMAN | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6314442599 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D., PHD | ||||||||
| NPICertificationDate: | 09/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 01379102 | 05 | NY | MEDICAID |