Provider Demographics
NPI:1003860354
Name:FALLON, EDMUND FRANCIS
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:FRANCIS
Last Name:FALLON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-0304
Mailing Address - Country:US
Mailing Address - Phone:518-926-6992
Mailing Address - Fax:518-926-6983
Practice Address - Street 1:135 NORTH RD
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:NY
Practice Address - Zip Code:12831-1308
Practice Address - Country:US
Practice Address - Phone:518-581-7256
Practice Address - Fax:518-926-1965
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108707207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00381177Medicaid
NYP00402828OtherRR MEDICARE
C11769Medicare UPIN
NY00381177Medicaid