Provider Demographics
NPI:1851395628
Name:FRIED, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FRIED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 N BELLE MEAD RD
Mailing Address - Street 2:
Mailing Address - City:E SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3456
Mailing Address - Country:US
Mailing Address - Phone:631-751-3000
Mailing Address - Fax:631-751-3366
Practice Address - Street 1:285 SILLS RD
Practice Address - Street 2:BLDG 16
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4808
Practice Address - Country:US
Practice Address - Phone:631-758-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY128126174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01337008Medicaid
NY19F441Medicare PIN
NYE17184Medicare UPIN