Provider Demographics
NPI:1568926822
Name:FREDERIC A MENDELSOHN NEURODIAGNOSTICS INC
Entity Type:Organization
Organization Name:FREDERIC A MENDELSOHN NEURODIAGNOSTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:A
Authorized Official - Last Name:MENDELSOHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-987-3705
Mailing Address - Street 1:30 SEASIDE DR
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1132
Mailing Address - Country:US
Mailing Address - Phone:631-987-3705
Mailing Address - Fax:
Practice Address - Street 1:30 SEASIDE DR
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1132
Practice Address - Country:US
Practice Address - Phone:631-987-3705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00655156Medicaid