Provider Demographics
NPI:1083060917
Name:GROENENDYK, SHELLY STEPHENS (MD)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:STEPHENS
Last Name:GROENENDYK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 ROCKY HILL RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT SINAI
Mailing Address - State:NY
Mailing Address - Zip Code:11766-1213
Mailing Address - Country:US
Mailing Address - Phone:801-205-1033
Mailing Address - Fax:
Practice Address - Street 1:75 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2190
Practice Address - Country:US
Practice Address - Phone:516-382-7399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2024-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10516430-1205207L00000X
TN63603207L00000X
NY329018207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology