Healthcare Provider Details

I. General information

NPI: 1871912790
Provider Name (Legal Business Name): JONATHAN KNEIB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NICOLLS RD RM 80
STONY BROOK NY
11794-9350
US

IV. Provider business mailing address

JONATHAN KNEIB P.O. BOX 1554
STONY BROOK NY
11790
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-2478
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number289098
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: