Healthcare Provider Details

I. General information

NPI: 1750320321
Provider Name (Legal Business Name): MARY ANDRIOLA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 10/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 N BELLE MEAD RD STE 5
EAST SETAUKET NY
11733-3495
US

IV. Provider business mailing address

HSC T12-020 NEUROLOGY DEPARTMENT
STONY BROOK NY
11794-8121
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-2599
  • Fax: 631-444-1474
Mailing address:
  • Phone: 631-444-2599
  • Fax: 631-444-1474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number174710
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: