Healthcare Provider Details

I. General information

NPI: 1902898240
Provider Name (Legal Business Name): JEFFREY HOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 NICHOLLS ROAD STONY BROOK UNIVERSITY MEDICAL CENTER
STONY BROOK NY
11790-0001
US

IV. Provider business mailing address

PO BOX 1559
STONY BROOK NY
11790-0989
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-0650
  • Fax:
Mailing address:
  • Phone: 631-444-0650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number210776
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number210776
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: