Healthcare Provider Details

I. General information

NPI: 1124105705
Provider Name (Legal Business Name): IRA CHERNOFF,MD PCI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NESCONSET HWY BLDG 20A
STONY BROOK NY
11790-2564
US

IV. Provider business mailing address

2500 NESCONSET HWY BLDG 20A
STONY BROOK NY
11790-2564
US

V. Phone/Fax

Practice location:
  • Phone: 631-246-6100
  • Fax: 631-246-9464
Mailing address:
  • Phone: 631-246-6100
  • Fax: 631-246-9464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number302541
License Number StateNY

VIII. Authorized Official

Name: MS. CYNTHIA A DI BELLA-PRICE
Title or Position: NURSE PRACTITIONER/FIRST ASSIST
Credential: NP-CFA
Phone: 631-246-6100