Provider Demographics
NPI:1699720888
Name:NEUROLOGY ASSOCIATES OF STONY BROOK, UNIVERSITY FACULTY PRACTICE CORPO
Entity type:Organization
Organization Name:NEUROLOGY ASSOCIATES OF STONY BROOK, UNIVERSITY FACULTY PRACTICE CORPO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:W
Authorized Official - Last Name:HALTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:631-444-2599
Mailing Address - Street 1:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0988
Mailing Address - Country:US
Mailing Address - Phone:631-444-8462
Mailing Address - Fax:
Practice Address - Street 1:101 NICOLLS RD RM 20
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-444-2599
Practice Address - Fax:631-441-4744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01379102Medicaid
NYW07171Medicare PIN