Healthcare Provider Details

I. General information

NPI: 1538392410
Provider Name (Legal Business Name): NEW YORK SPINE AND BRAIN SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2009
Last Update Date: 11/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HSC T12 RM 080
STONY BROOK NY
11794-8122
US

IV. Provider business mailing address

HSC T12 RM 080
STONY BROOK NY
11794-8122
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-8070
  • Fax: 631-444-1535
Mailing address:
  • Phone: 631-444-8070
  • Fax: 631-444-1535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number305171
License Number StateNY

VIII. Authorized Official

Name: DR. RAPHAEL DAVIS
Title or Position: CHAIRMAN
Credential: M.D.
Phone: 631-444-8070