Provider Demographics
NPI:1083692230
Name:FRADLIS MEDICAL CARE PC
Entity Type:Organization
Organization Name:FRADLIS MEDICAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRSIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IOSIF
Authorized Official - Middle Name:
Authorized Official - Last Name:FRDALIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-891-6500
Mailing Address - Street 1:606 MICHELLE PL
Mailing Address - Street 2:
Mailing Address - City:NORTH WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2829 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7858
Practice Address - Country:US
Practice Address - Phone:718-891-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2074282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01880189Medicaid
NYG68257Medicare UPIN
NYW39821Medicare ID - Type Unspecified