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General NPI Number Information
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NPI Number | 1083060917
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Entity Type | Individual
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Provider Name | SHELLY STEPHENS GROENENDYK MD
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Gender | Female
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Dates
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Enumeration Date | 05/10/2016
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Last Update Date | 11/03/2024
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Provider Practice Location Address
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Address Line | 75 N COUNTRY RD
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-2190
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Country | US
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Telephone | 516-382-7399
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Fax |
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Provider Business Mailing Address
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Address Line | 25 ROCKY HILL RD
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City | MOUNT SINAI
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State | NY
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Zip | 11766-1213
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Country | US
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Telephone | 801-205-1033
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 10516430-1205
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 63603
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License Number State | TN
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Taxonomy #3
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 329018
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License Number State | NY
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