Basic Information
| Provider Information | |||||||||
| NPI: | 1750320321 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ANDRIOLA | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | HSC T12-020 NEUROLOGY DEPARTMENT | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117948121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314442599 | ||||||||
| FaxNumber: | 6314441474 | ||||||||
| Practice Location | |||||||||
| Address1: | 181 N BELLE MEAD RD STE 5 | ||||||||
| Address2: | |||||||||
| City: | EAST SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117333495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314442599 | ||||||||
| FaxNumber: | 6314441474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 10/18/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | 174710 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
| ID | Type | State | Issuer | Description | 4427041 | 01 | NY | AETNA | OTHER | 28E512 | 01 | NY | EMPIRE BC/BS | OTHER | 01088251 | 05 | NY | MEDICAID |