Provider Demographics
NPI:1093875601
Name:FRIED, ROBERT M
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:FRIED
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 1:97 CEDARHURST AVE
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-2137
Mailing Address - Country:US
Mailing Address - Phone:516-569-0383
Mailing Address - Fax:
Practice Address - Street 1:97 CEDARHURST AVE
Practice Address - Street 2:
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516-2137
Practice Address - Country:US
Practice Address - Phone:516-569-0383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004826174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00056953Medicare PIN
NYP53481Medicare PIN
NY00305Medicare PIN
NYU19893Medicare UPIN