Provider Demographics
NPI:1598855058
Name:ADVANCED REHABILITATION MEDICINE PLLC.
Entity Type:Organization
Organization Name:ADVANCED REHABILITATION MEDICINE PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:L
Authorized Official - Last Name:FANELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-474-6049
Mailing Address - Street 1:200 BELLE TERRE RD
Mailing Address - Street 2:SUITE E140
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1928
Mailing Address - Country:US
Mailing Address - Phone:631-474-6879
Mailing Address - Fax:631-474-6448
Practice Address - Street 1:200 BELLE TERRE RD
Practice Address - Street 2:SUITE E140
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1928
Practice Address - Country:US
Practice Address - Phone:631-474-6879
Practice Address - Fax:631-474-6448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02289747Medicaid
NY02289747Medicaid