Healthcare Provider Details

I. General information

NPI: 1366497448
Provider Name (Legal Business Name): STONY BROOK RADIOLOGY, UNIVERSITY FACULTY PRACTICE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SUNY AT STONY BRK HSC, L4, RM 120
STONY BROOK NY
11794-8460
US

IV. Provider business mailing address

PO BOX 1554
STONY BROOK NY
11790-0988
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-3452
  • Fax:
Mailing address:
  • Phone: 631-444-3452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ELAINE S GOULD
Title or Position: CHAIR PERSON
Credential: M.D.
Phone: 631-444-3452