Healthcare Provider Details

I. General information

NPI: 1467451120
Provider Name (Legal Business Name): MAURY J GREENBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NESCONSET HWY BLDG 6D
STONY BROOK NY
11790-2555
US

IV. Provider business mailing address

2500 NESCONSET HWY BLDG 6D
STONY BROOK NY
11790-2555
US

V. Phone/Fax

Practice location:
  • Phone: 631-751-5550
  • Fax:
Mailing address:
  • Phone: 631-751-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number154568
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME80844
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: