Healthcare Provider Details

I. General information

NPI: 1073603734
Provider Name (Legal Business Name): GEORGE G. FAIREY MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 N COUNTRY RD STE 2A
STONY BROOK NY
11790-1919
US

IV. Provider business mailing address

1212 N COUNTRY RD STE 2A
STONY BROOK NY
11790-1919
US

V. Phone/Fax

Practice location:
  • Phone: 631-689-5155
  • Fax:
Mailing address:
  • Phone: 631-689-5155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number129972
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number129972
License Number StateNY

VIII. Authorized Official

Name: GEORGE G. FAIREY
Title or Position: OWNER
Credential: M.D.
Phone: 631-689-5155