Healthcare Provider Details

I. General information

NPI: 1033436662
Provider Name (Legal Business Name): SHENNAN AIBEL WEISS M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2010
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NICOLLS RD RM 20
STONY BROOK NY
11794-5211
US

IV. Provider business mailing address

909 WALNUT ST 2ND FLOOR
PHILADELPHIA PA
19107-5211
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-2599
  • Fax:
Mailing address:
  • Phone: 215-955-1234
  • Fax: 215-955-3745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number300830-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD457821
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: