Provider Demographics
NPI:1518231463
Name:JILL M FETELL
Entity Type:Organization
Organization Name:JILL M FETELL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:M
Authorized Official - Last Name:FETELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-362-8400
Mailing Address - Street 1:13-15 NEPERAN RD
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-3446
Mailing Address - Country:US
Mailing Address - Phone:914-631-7911
Mailing Address - Fax:
Practice Address - Street 1:26 FIREMENS MEMORIAL DR
Practice Address - Street 2:SUITE 115
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-3553
Practice Address - Country:US
Practice Address - Phone:845-362-8400
Practice Address - Fax:845-362-8474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYA145931-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty