Provider Demographics
NPI:1457510299
Name:MARC J FEDERBUSCH DPM
Entity Type:Organization
Organization Name:MARC J FEDERBUSCH DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:FEDERBUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:718-366-3338
Mailing Address - Street 1:6534 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-6212
Mailing Address - Country:US
Mailing Address - Phone:718-366-3338
Mailing Address - Fax:718-366-2633
Practice Address - Street 1:6534 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-6212
Practice Address - Country:US
Practice Address - Phone:718-366-3338
Practice Address - Fax:718-366-2633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003554213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5330080001Medicare NSC